Evidence Report/Technology Assessment 

Number 147 

The Effectiveness of Different Methods of Toilet 

Training for Bowel and Bladder Control 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov 

Contract No. 290-02-0023 

Prepared by

University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada

Investigators 

Terry P. Klassen, M.D., M.S., F.R.C.P.C. 

Darcie Kiddoo, M.D., F.R.C.S.C. 

Mia E. Lang, M.D., Ph.D., F.A.A.P., F.R.C.P.C. 

Carol Friesen, M.L.I.S., M.A. 

Kelly Russell, B.Sc. 

Carol Spooner, M.S., B.Sc.N. 

Ben Vandermeer, M.S. 

AHRQ Publication No. 07-E003 

December 2006 
This report is based on research conducted by the University of Alberta Evidence-based Practice 

Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), 

Rockville, MD (Contract No. 290-02-0023). The findings and conclusions in this document are 

those of the author(s), who are responsible for its content, and do not necessarily represent the 

views of AHRQ. No statement in this report should be construed as an official position of AHRQ 

or of the U.S. Department of Health and Human Services. 

The information in this report is intended to help clinicians, employers, policymakers, and others 

make informed decisions about the provision of health care services. This report is intended as a 

reference and not as a substitute for clinical judgment. 

This report may be used, in whole or in part, as the basis for the development of clinical practice 

guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage 

policies. AHRQ or U.S. Department of Health and Human Services endorsement of such 

derivative products may not be stated or implied. 
ii

This document is in the public domain and may be used and reprinted without permission except 

those copyrighted materials noted for which further reproduction is prohibited without the 

specific permission of copyright holders. 

Suggested Citation: 

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. Evidence 

Report/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. 
iii

Preface 

 The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based 

Practice Centers (EPCs), sponsors the development of evidence reports and technology 

assessments to assist public- and private-sector organizations in their efforts to improve the 

quality of health care in the United States. The reports and assessments provide organizations 

with comprehensive, science-based information on common, costly medical conditions and new 

health care technologies. The EPCs systematically review the relevant scientific literature on 

topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to 

developing their reports and assessments. 

 To bring the broadest range of experts into the development of evidence reports and health 

technology assessments, AHRQ encourages the EPCs to form partnerships and enter into 

collaborations with other medical and research organizations. The EPCs work with these partner 

organizations to ensure that the evidence reports and technology assessments they produce will 

become building blocks for health care quality improvement projects throughout the Nation. The 

reports undergo peer review prior to their release. 

 AHRQ expects that the EPC evidence reports and technology assessments will inform 

individual health plans, providers, and purchasers as well as the health care system as a whole by 

providing important information to help improve health care quality. 

 We welcome comments on this evidence report. They may be sent by mail to the Task Order 

Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, 

Rockville, MD 20850, or by e-mail to epc@ahrq.gov. 

Carolyn M. Clancy, M.D. 

Director 

Agency for Healthcare Research and Quality 

Jean Slutsky, P.A., M.S.P.H. 

Director, Center for Outcomes and Evidence 

Agency for Healthcare Research and Quality 

Beth A. Collins Sharp, Ph.D., R.N. 

Director, EPC Program 

Agency for Healthcare Research and Quality 

Steven Fox, M.D., S.M., M.P.H. 

EPC Program Task Order Officer 

Agency for Healthcare Research and Quality 
iv

Acknowledgments 

We thank the members of the technical expert panel for providing scope and direction for the 

contents of the review and the peer reviewers for providing invaluable input on the draft report. 

The names of these individuals are listed in Appendix F (available on the AHRQ Web site at 

http://www.ahrq.gov/clinic/tp/toilettrtp.htm). We are grateful to the following people for their 

efforts: 

 Liza Bialy for implementing the quality assessment and data extraction forms within the 

online SRS system and for assisting with quality assessment. 

 Nicola Hooton for verifying the extracted data. 

 Donna Dryden for editing and providing feedback on the draft of this report. 

 Lisa Malinowski and Kenneth Moreau for collecting potentially relevant studies. 
v

Structured Abstract

Objectives: The objectives of this report are to determine the following: (1) the effectiveness of 

the toilet training methods, (2) which factors modify the effectiveness of toilet training, (3) if the 

toilet training methods are risk factors for adverse outcomes, and (4) the optimal toilet training 

method for achieving bowel and bladder control among patients with special needs. 

Data Sources: MEDLINE®, Ovid MEDLINE® In-Process & Other Non-Indexed Citations, Ovid 

OLDMEDLINE®, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL®, 

PsycINFO®, ERIC®, EBM Reviews, HealthSTAR, AMED, Web of Science®, Biological 

Abstracts, Sociological Abstracts, OCLC ProceedingsFirst, OCLC PapersFirst, Dissertation 

Abstracts, Index to Theses, National Research Register’s Projects Database, and trials registers. 

Review Methods: Two reviewers assessed the studies for inclusion. Studies were included if 

they met the following criteria: Study design: RCT, CCT, prospective or retrospective cohort, 

case-control, cross-sectional or case-series; Population: infants, toddlers, or children with or 

without co-morbidities, neuromuscular, cognitive, or behavioral handicaps disabilities; 

Intervention: at least one toilet training method; and Outcome: bladder and/or bowel control, 

successes, failures, adverse outcomes. Methodological quality was assessed independently by 

two reviewers. Data were extracted by one reviewer and a second checked for accuracy and 

completeness. Due to substantial heterogeneity, meta-analysis was not possible. 

Results: Twenty-six observational studies and eight controlled trials were included. 

Approximately half of the studies examined healthy children while the remaining studies 

assessed toilet training of mentally or physically handicapped children. For healthy children, the 

Azrin and Foxx method performed better than the Spock method, while child-oriented combined 

with negative term avoidance proved better than without. For mentally handicapped children, 

individual training was superior to group methods; relaxation techniques proved more 

efficacious than standard methods; operant conditioning was better than conventional treatment, 

and the Azrin and Foxx and a behavior modification method fared better than no training. The 

child-oriented approach was not assessed among mentally handicapped children. For children 

with Hirschsprung’s disease or anal atresia, a multi-disciplinary behavior treatment was more 

efficacious than no treatment. 

Conclusions: Both the Azrin and Foxx method and the child-oriented approach resulted in quick, 

successful toilet training, but there was limited information about the sustainability of the 

training. The two methods were not directly compared; thus, it is difficult to draw definitive 

conclusions regarding the superiority of one method over the other. In general, both programs 

may be used to teach toilet training to healthy children. The Azrin and Foxx method and operant 

conditioning methods were consistently effective for toilet training mentally handicapped 

children. Programs that were adapted to physically handicapped children also resulted in 

successful toilet training. A lack of data precluded conclusions regarding the development of 

adverse outcomes. 

vii

Contents 

Executive Summary ........................................................................................................................1 

Evidence Report.............................................................................................................................. 7 

Chapter 1. Introduction ................................................................................................................... 9 

Toilet Training ............................................................................................................................ 9 

What is Toilet Training? ......................................................................................................... 9 

Evolution of Toilet Training ................................................................................................... 9 

Toilet Training Methods ....................................................................................................... 10 

Current Recommendations.................................................................................................... 12 

Factors Related to Toilet Training ........................................................................................ 13 

Adverse Outcomes During Toilet Training .......................................................................... 16 

Objectives of this Review ......................................................................................................... 19 

Key Questions........................................................................................................................... 21 

Chapter 2. Methods....................................................................................................................... 23 

Methods for the Systematic Review ......................................................................................... 23 

Literature Search................................................................................................................... 23 

Selection and Inclusion......................................................................................................... 23 

Quality Assessment............................................................................................................... 25 

Data Extraction ..................................................................................................................... 25 

Data Analysis........................................................................................................................ 26 

Peer Review .......................................................................................................................... 27 

Chapter 3. Results ......................................................................................................................... 29 

Literature Search................................................................................................................... 29 

Description of Included Studies............................................................................................ 30 

Methodological Quality of Included Studies ........................................................................ 31 

Toilet Training Success......................................................................................................... 32 

Direct Comparisons .............................................................................................................. 32 

Single Cohorts....................................................................................................................... 36 

Chapter 4. Discussion ................................................................................................................... 41 

Toilet Training Healthy Children.......................................................................................... 41 

Toilet Training Physically Handicapped Children ............................................................... 43 

Modifying Factors that May Affect Toilet Training............................................................. 44 

Adverse Outcomes Associated with Toilet Training............................................................ 44 

Limitations ............................................................................................................................ 45 

Future Research Opportunities ............................................................................................. 47 

Conclusions........................................................................................................................... 48 

References and Included Studies .................................................................................................. 51 
viii

Tables 

Table 1. Trends in recommended infant training methods extracted from three women’s 

magazines from 1898-1948.............................................................................................10 

Table 2. Summary of toilet training guidelines .............................................................................19 

Table 3. Inclusion and exclusion criteria for review on the effectiveness of different methods 

 for bladder and bowel control .........................................................................................24 

Table 4. Summary of components of Downs and Black Score .....................................................31 

Figures

Figure 1. Analytical framework for the effectiveness of different methods of toilet training for 

bowel and bladder control...............................................................................................20 

Figure 2. Selection of Included Studies ......................................................................................... 29 

Figure 3. Percent of Successful Toilet Training Among Healthy Children...................................55 

Figure 4. Percent of Successful Toilet Training Among Mentally Handicapped Children...........56 

Figure 5. Percent of Successful Toilet Training Among Physically Handicapped Children.........57 

Appendixes 

Appendix A: Exact Search Strings 

Appendix B: Sample Forms 

Appendix C: Multiple Publications of Toilet Training Cohorts 

Appendix D: Evidence Tables 

Appendix E: List of Excluded Studies 

Appendix F: Technical Expert Panel and Peer Reviewers 

Appendix G: Abbreviations 

Appendix H: Toilet Training Methods 

Appendixes and evidence tables for this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/toilettrtp.htm.
1

Executive Summary 

Introduction 

Toilet training is the mastery of skills necessary for urinating and defecating in a socially 

acceptable time and manner. In many cultures, parents regard the achievement of independent 

toileting as a significant accomplishment and a step toward self-sufficiency. Bladder and bowel 

function is regulated by complex muscles and may be modified by physiological, psychological, 

social, and cultural factors. Currently, an all-encompassing definition of “toilet trained” is 

lacking, and there are no strict criteria stating how long a child must be bladder or bowel 

continent, or what components of the toileting process a child must accomplish independently, in 

order to be considered “toilet trained.” 

Over the last 100 years, recommended toilet training methods have oscillated between rigid 

programs and child-oriented ones. In 1962, Brazelton developed the “child readiness” approach, 

which focused on gradual training. This approach described parameters of child and parent toilet 

training readiness. The Azrin and Foxx method emerged in 1971 as a parent-oriented method 

that emphasized structured behavioral endpoint training aimed at eliciting a specific chain of 

independent events by teaching the component skills of toilet training. These two methods differ 

with respect to goal development, endpoints, and emphasis on the child’s self-esteem. Other 

methods include variations of operant conditioning, assisted infant toilet training, and the Spock 

method. The toilet training methods are described in Appendix H∗. 

Some factors believed to impact toilet training include sex, age at initiation, race, physical or 

mental handicaps, and constipation. While the majority of children are toilet trained without 

incident, approximately 2 to 3 percent experience an adverse outcome. Common adverse events 

are enuresis, encopresis, stool toileting refusal, stool withholding, and hiding while defecating. 

Toilet training children with special needs presents a unique set of challenges as impaired 

communication skills, reduced ability to process sensory information, and mobility and 

neurophysiological deficits add challenges to their toilet training. 

Current published toilet training guidelines in North America recommend (1) a child-oriented 

approach, (2) not starting before 18 months because the child is not physically ready, and, (3) 

starting when the child displays interest.

Objectives and Key Questions 

The American Academy of Pediatrics put forth the following four questions: 

1. What is the evidence for effectiveness of various toilet training methods to achieve bowel 

and bladder control? 

2. What factors modify the effectiveness of toilet training, such as age, sex, race, ethnicity, 

culture, age at initiation, constipation, or stool toileting refusal? 

 

∗

 Appendixes and Evidence Tables are provided electronically at http://www.ahrq.gov/clinic/tp/toilettrtp.htm
2

3. What is the evidence for various toilet training methods as a risk factor for adverse 

outcomes, such as dysfunctional voiding, enuresis, encopresis, later problems, and 

psychological consequences? 

4. What is the effectiveness of toilet training methods for achieving bowel and bladder 

control among patients with special needs? 

Methods 

Literature Search 

Search terms were adapted for the following electronic databases: MEDLINE®, Ovid 

MEDLINE® In-Process & Other Non-Indexed Citations, Ovid OLDMEDLINE®, Cochrane 

Central Register of Controlled Trials, EMBASE, CINAHL®, PsycINFO®, ERIC®, EBM 

Reviews, HealthSTAR, AMED, Web of Science®, Biological Abstracts, Sociological Abstracts, 

OCLC ProceedingsFirst, OCLC PapersFirst, Dissertation Abstracts, Index to Theses, NLM 

Gateway, and the National Research Register’s Projects Database. Trials registers were searched 

and position statements were sought. In addition, annual conference proceedings were hand 

searched and the reference lists were reviewed. Only studies published in English were included. 

Study Selection 

Each title and when available, abstract was independently screened by two reviewers and 

assessed for inclusion using a standardized form. References identified as “potentially relevant” 

and “unclear” were then screened by a pediatrician and a pediatric urologist. The full texts of 

potentially relevant articles were retrieved. 

Using a priori inclusion criteria, two reviewers independently assessed the full text articles. 

Studies that examined the treatment of enuresis or encopresis were excluded; however, those that 

measured the development of enuresis or encopresis as the result of a specific toilet training 

method were included. Disagreement among reviewers was resolved by discussion and 

consulting a third party as needed. 

Quality Assessment 

Two reviewers independently assessed the methodological quality. The quality of 

observational cohort studies was assessed using Downs and Black’s partially validated 

“Checklist of the assessment of methodological quality of both randomized and non-randomized 

studies of health care interventions.” The Jadad Scale and allocation concealment were used to 

assess the methodological quality of randomized and non-randomized controlled clinical trials. 

Data Extraction 

Data were extracted by one reviewer and checked for accuracy and completeness by a 

second. Data describing study design, toilet training objective (bladder vs. bowel; daytime vs. 

nighttime; self-directed vs. assisted), patient demographics, source of the study population, toilet 
3

training interventions and associated details, and outcomes were extracted. All outcomes 

reporting change in bladder and bowel function, number of successes and accidents, success and 

failure rates, time to toilet train, and the occurrence of adverse events were extracted. Whenever 

possible, information was extracted pertaining to effect modifiers. 

Data Analysis 

Due to extreme clinical heterogeneity in study designs, interventions, populations, and 

outcomes, no statistical meta-analysis was performed. Studies were organized by population 

(healthy, mentally challenged, or physically challenged) and the toilet training programs were 

categorized as Azrin and Foxx, child-oriented, operant conditioning, or other. In a few instances 

Fisher’s exact test was used to compute a p-value to compare dichotomous data between two 

groups. 

Results 

Direct Comparisons 

There were three randomized trials involving healthy children; none compared the childoriented approach to the Azrin and Foxx method. In healthy children the Azrin and Foxx 

method performed better than the Spock method (trained without force) for both day and night 

toilet training. Negative term avoidance using the child-oriented method significantly reduced 

the time of stool toileting refusal and time to toilet training compared to the child-oriented 

method alone. 

In mentally challenged children, individual training was more effective than group methods 

for toilet training, although neither appeared to have long term effectiveness. Relaxation showed 

some effectiveness in reducing accidents over standard methods. An operant conditioning 

method was also found to be superior to both conventional and control groups in achieving 

urination and defecation in the toilet. The Azrin and Foxx method showed significant reductions 

in dampened pants compared to no training. Behavior modification methods improved toilet 

training habits over no training. 

A multi-disciplinary behavior treatment was found effective in improving toileting habits of 

children with Hirschsprung’s disease and anal atresia.

Single Cohort 

Healthy children. In Taubman’s 1997 study, 482 children from middle- and upper-class families 

were toilet trained using a child-oriented approach. Twenty-two percent experienced at least one 

month of stool toileting refusal (STR) and 13 percent developed stool withholding during 

training. Twenty-nine children required an intervention. In a second study, Brazelton described 

toilet training results of 1170 children from upper-middle class families over ten years. All used 

a child-oriented approach beginning at approximately 18 months of age. Daytime continence for 

all was achieved by a mean age of 28.5 months and nighttime continence by 33.3 months. By 

five years of age, 16 children suffered from at least one of the following problems: enuresis (12), 
4

soiling in stressful situations (4), and chronic constipation (8). Kaffman examined children living 

in kibbutzim in Israel who were trained using an individualized child-oriented program. The 

prevalence of enuresis at 3.5 years was 13.9 percent (192/1376). 

Foxx and Azrin identified 34 children from the community who passed a readiness test. Post 

training, bladder and bowel accidents were reduced by 97 percent and success was maintained at 

four-month follow-up. A second study examined 49 children who were trained using Azrin and 

Foxx’s Toilet Training in Less than a Day (TTLD) program. Ten children failed to achieve 

continence within the intensive training session because of the child’s severe emotional reaction 

or the parents quitting the program. In both studies children were trained in approximately 4.5 

hours. 

Mentally handicapped children. Didden used the Azrin and Fox method in an attempt to 

achieve prompted bowel or bladder control in six children with Angelman Syndrome. The 

average frequency of correct daily toileting increased from 0.8 to 3.5 at post-treatment and to 3.1 

at 2.5 years follow-up. Lancioni trained nine profoundly deaf and blind children who had never 

shown any signs of self-initiated toileting. The training program included positive reinforcement 

and punishment. At day 44, eight of the nine children exhibited self-initiated toileting. Smith 

retrospectively examined 13 mentally retarded children trained using the Azrin and Foxx method 

and a urinary training device. Frequency of wetting declined from 50 percent to 10 percent by 

week 5 and this result was sustained at follow-up. In the final study of nine mentally 

handicapped children, the Azrin and Foxx method was augmented with daily reading of a toilet 

training book. The number of successes increased. There was poor compliance to the book and it 

was deemed unnecessary. 

Five studies examined variants of operant conditioning programs. Van Wagenen used a 

forward-moving series of actions and urine alarms to successfully train nine mentally 

handicapped children. Ando used operant conditioning to toilet train five institutionalized autistic 

boys. The program involved positive reinforcement and punishment. Four children improved 

self-initiating toileting, while the remaining child did not respond to any reinforcers. Giles 

attempted to toilet train five severely and profoundly mentally retarded children using positive 

reinforcement and, if it did not produce continence, punishment was used. All five were 

successfully toilet trained in 8 weeks. Spencer attempted to establish bowel control in 38 

severely and profoundly retarded boys using a six-week program consisting of positive 

reinforcement for sitting on the toilet and defecating in the toilet. Spontaneous toileting increased 

by 9 percent and accidents decreased by 17 percent. Using operant conditioning, Colwell 

attempted to bring toileting behaviors under verbal control in 47 profoundly and severely 

mentally retarded children. Of this group, 33 children improved in skill, 3 worsened, and the 

remaining 8 experienced no change. 

Physically handicapped children. Van Kuyk retrospectively assessed a multidisciplinary 

program for 43 children with anal atresia and for 16 with Hirschsprung’s disease. The program 

aimed to teach adequate defecation behavior by reducing fear and anxiety, using the lower body 

to improve straining techniques, and adopting a regular schedule. There was a significant 

improvement in the Templeton continence score in children with anal atresia (from 2.2 ± 0.45 to 

1.6 ± 0.59) and significantly fewer children suffered from constipation (18 vs 8). The 16 boys 

with Hirschsprung’s disease also had a significant improvement in Templeton score (from 2.7 ± 

0.48 to 1.1 ± 0.34 at post treatment) and there were fewer constipated boys. 
5

Three studies developed toilet training programs for establishing bowel control in children 

with spina bifida. King aimed to establish neurogenic bowel habituation in 35 patients. In 

children ≤6 years old, continence improved from 0 (0/17) to 65 percent (11/17) and it improved 

further to 88 percent (8/9) among children who completed the program. Forsythe created a 

similar stepwise program for 47 children. A combination of regular toileting, initial enemas, and 

laxatives was the most effective. Sullivan-Bolyai evaluated a component-based toilet training 

program in 525 children with spina bifida. Of 184 children >4 years of age, 141 were socially 

acceptably trained using suppositories, expansion enemas or timed evacuations. Regardless of 

age, 44 children failed to achieve bowel control. Forty-six children <6 years of age achieved 

socially acceptable bladder control mainly with diaper or pants inserts, and clean intermittent 

catheterization. Of 158 children >6 years of age, 107 achieved socially acceptable bladder 

control, primarily by ileal diversion and clean intermittent catheterization. In both age groups, 62 

children did not achieve socially acceptable bladder control.

Adverse outcomes. Only four studies specifically addressed adverse outcomes. In a case-control 

study among school aged children, Bakker found that those who were trained at a later age (>18 

months) and by more aggressive training methods had more lower urinary tract symptoms. 

Kaffman reported the frequency of enuresis in 6 and 7 year-old children trained by multiple 

caregivers on a kibbutz to be higher than non-kibbutz raised children, but lower after 10 years of 

age. Taubman reported an incidence of roughly 22 percent for stool toileting refusal, 53 percent 

for stool withholding, and 69 percent for hiding to defecate that occurred during the training 

process; this was associated with the presence of younger siblings, parental difficulty in setting 

limits, and late (>42 months) training. In contrast, Brazelton 1962 reported a 1.4 percent 

incidence of residual problems >5 years of age following a child-oriented training approach. 

None of the Azrin and Foxx studies reported these outcomes. 

Discussion 

Effectiveness of Toilet Training 

In general, both the child-oriented and Azrin and Foxx approaches seem able to teach toilet 

training to healthy children. The regimented Azrin and Foxx approach seems to result in rapid 

success rates at relatively young ages and results are maintained. 

Based on single-arm studies, mentally handicapped children had some degree of success 

regardless of the toilet training method. A limited number of studies was identified with most 

published from 1966 to 1981. Since then, the definition of mental handicap has been revised; 

therefore, some of the children classified as mentally handicapped in the older studies may not 

meet the current definition. 

One of the key questions asked to identify toilet training strategies and/or outcomes of 

children with behavior problems. Unfortunately no studies were identified. Children with 

complex medical conditions should not be expected to toilet train as healthy children, and no 

studies evaluating standard methods among physically handicapped children were located. The 

results of cohort studies confirmed that children with Hirschprung’s disease or anal atresia could 

achieve continence with a multidisciplinary approach. Due to spinal cord neurologic impairment, 

children with spina bifida can suffer from constipation and/or fecal incontinence as well as 
6

urinary symptoms such as failure to empty or incontinence. The primary means to control 

elimination problems are timed evacuation via clean intermittent catheterization, stool softeners, 

suppositories, and enemas.

Potential Limitations 

The main limitation is the lack of research conducted and reported in the area of toilet 

training and the heterogeneity among the populations studied, the toilet training programs 

evaluated, and the definitions of success. As a consequence of this heterogeneity, the pooling of 

results was not possible. Additional limitations include analyses conducted in the primary 

studies, several of which did not perform a statistical analysis of their data. Finally, a descriptive 

analysis has several limitations and leaves the clinical reader with less information to guide 

future actions.

Future Research Opportunities 

Given the findings of this systematic review, the following research priorities are recommended: 

• Standardize definitions of “toilet trained,” “success,” and “failure” and adapt them to 

cultural differences when appropriate. 

• Conduct trials that directly compare two toilet training methods, such as Azrin and Foxx 

and the child-oriented approach, within the same population. 

• Accurately describe the populations in terms of mental and/or physical challenges, using 

current diagnostic standards. 

• Conduct toilet training programs with children suffering from behavioral disorders such 

as attention-deficit disorder and oppositional defiant disorder. 

• Determine if toilet training is affected by age, sex, race, culture, etc. 

• Document adverse outcomes. 

Conclusions 

There is a lack of high-quality research to guide clinicians in advising parents and guardians 

on how to toilet train their children. Based on the evidence, the following conclusions can be 

made: 

• The strategies appear similar among healthy children, thus caregivers and health care 

providers can try any of the methods. 

• Some mentally handicapped children can attain at least partial success with toilet 

training. 

• Given the range of functionality among mentally handicapped children and the potential 

for concurrent physical and behavior problems, toilet training programs may need to be 

flexible. 

• Toilet training physically handicapped children is enhanced by a multidisciplinary team. 

• Elimination problems should be treated early to encourage normal psychosocial 

development. 
Evidence Report

9

Chapter 1. Introduction 

Toilet Training 

What is Toilet Training? 

Toilet training is the acquisition of skills necessary for urinating and defecating in a toilet at a 

socially acceptable time and age. It is a heterogeneous process influenced by many 

physiological, psychological, social, and cultural factors. Complex muscular physiology 

regulates bladder and bowel function.1

 Because the infant central nervous system is not 

completely developed, the bladder empties involuntarily as a result of spinal reflexes 

approximately 20 times a day.2

 As children develop, they gain the ability to recognize that their 

bladder is full and to retain urine until it is appropriate to void. Defecation occurs once the 

rectum contains a sufficient volume of feces. As the rectum fills with feces from the colon, the 

rectum expands and the internal anal sphincter relaxes; anal pressure is reduced and the desire to 

defecate is felt. A combination of the relaxation of the external anal sphincter, bowel 

contractions, and an increase in intra-abdominal pressure achieved by straining results in 

defecation. The external anal sphincter can be voluntarily contracted if defecation is not 

appropriate. 

An all-encompassing definition of “toilet trained” does not exist. For instance, there are no 

strict criteria stating how long a child must be bladder or bowel continent to be considered toilet 

trained and often the definition of success is dependent on the specific toilet training approach.3

In addition, it is unclear what components of the toileting process the child must accomplish 

independently, such as undressing and dressing, flushing the toilet, or washing hands, to be 

considered toilet trained.3

 Western culture perceives the meaning of “toilet trained” to extend 

beyond the absence of bladder and bowel accidents and to include toileting in socially acceptable 

places, toileting in a proper posture, and complete toileting in a sanitary manner.4

Evolution of Toilet Training 

In North America toilet training methods have oscillated over the last century (Table 1).3

 In 

the late 1800s and early 1900s toilet training was considered a passive and permissive process 

and was primarily determined by parents. During the 1920s and 1930s a new generation of 

behavioral scientists emerged and toilet training was regarded as a rigid habit-training process, 

but it was still determined by parents. The objective of toilet training was to quickly alleviate the 

burden of infant wetting and soiling.5 In 1932 the American government published Infant Care 

and suggested that toilet training was to be completed by six to eight months of age.6

 Training 

was coercive in nature; experts recommended the use of “soap stick” rectal conditioners to assist 

in bowel training. The importance of regularity and the scheduling of bowel movements were 

also stressed. 
10

By the 1940s it was hypothesized that rigid toilet training resulted in the failure to achieve 

bowel and bladder continence and that it may elicit behavioral problems.7 In addition, research 

had shown that children do not develop voluntary bladder and bowel control until approximately 

9 months of age. Toilet training reverted to a child-oriented approach and parents were advised 

to begin toilet training once the child displayed interest in the process. In 1962 Brazelton 

developed the “child readiness” approach.8

 This was followed by the Azrin and Foxx method 

that focused on structured behavioral endpoint oriented training.9 As toilet training moved from 

rigid parent-driven methods to child-oriented ones, the age at which toilet training was initiated 

increased. 

Table 1. Trends in recommended infant training methods extracted from three women’s magazines from 

1898-1948* 

Year Mother-determined 

Readiness 

Early Readiness, Rigid 

Environmental Scheduling 

Child-oriented Readiness 

(2–3 years)

1890 100% 0% 0% 

1900 78% 22% 0% 

1910 23% 77% 0% 

1920 0% 100% 0% 

1930 0% 75% 25% 

1940 0% 33% 66% 

1948 0% 0% 100% 

*Adapted from Vincent et al.10 and published in deVries 1977

 

Toilet Training Methods 

The two primary toilet training methods used in Western societies are the child-oriented 

method and the Azrin and Foxx method. Both methods suggest that toilet training commence at 

approximately 18 months of age and that the child should be successfully toilet trained between 

2 to 3 years of age.3

 The two methods differ with respect to goal development, endpoints, and 

emphasis on the child’s self-esteem. Additional toilet training methods include variations of 

operant conditioning and assisted infant toilet training. The toilet training methods are described 

in greater detail in Appendix H∗

. 

Child-oriented. In 1962 Brazelton developed a child-oriented program that focused on gradual 

training.3

 Brazelton described how he determined child and parent(s) was ready to begin toilet 

training. Toilet readiness is a combination of both child and parent willingness to participate in 

toilet training. The parent responds to the child’s signals that the child is ready to begin toilet 

training. In addition, the parent must be willing to toilet train the child and be aware of training 

obstacles, such as the child attending daycare or any physical or mental disabilities the child may 

have. 

The child must be physiologically and behaviorally ready to toilet train. Examples of child 

readiness include exhibiting some degree of bladder and bowel control, having the neurological 

 

∗

 Appendixes and Evidence Tables are provided electronically at http://www.ahrq.gov/clinic/tp/toilettrtp.htm
11

maturity to co-operate, and voluntarily participate in toilet training. It is believed that these 

components are not developed until the child is approximately 18 months old. 

To toilet train the child, the child should become familiar with his own chair and sit on it 

while fully clothed. Once co-operation has been established, the child may sit on the chair 

without a diaper. The next step is to empty the diaper contents into the chair while explaining to 

the child that this where eliminations go. Once the child understands the chair, the child can be 

encouraged to use it independently and can begin wearing training pants. 

Azrin and Foxx. Behavioral analysis and structured behavioral training were popular in the 

1960s and 1970s and were subsequently applied to toilet training. The Azrin and Foxx method 

emerged in 1971 as a parent-oriented method that emphasized structured behavioral endpoint 

training aimed at eliciting a specific chain of independent events by teaching the component 

skills of toilet training.9

 Although the Azrin and Foxx method was specifically designed for 

achieving bladder continence, it has been adapted successfully for bowel control. 

The Azrin and Foxx method described the first set of objective criteria parents could use to 

determine if their child was ready for toilet training.3

 The component skills include both 

physiological readiness (having periods of dryness and being physically able to perform tasks 

related to toilet training) and psychological readiness (able to follow instructional skills).3

Physiological readiness assesses adequate muscle tone required for independent toileting. Tasks 

may include walking short distances, dressing, and sitting upright. Psychological readiness 

establishes if the child understands the instructions and is motivated to adopt independent toilet 

training. Examples of psychological components are pointing to body parts and imitating a task.3

By completing the majority of the pre-defined tasks, a child proves able to complete complex 

motor tasks beyond eliminating at the proper time. 

The child participates by recognizing appropriate elimination stimulus. This is a four-step 

stimulus-control model that is executed by (1) increasing fluid intake, (2) scheduling toilet 

training time, (3) positive reinforcing correct behavior, and (4) over-correcting accidents. 

The Azrin and Foxx method is rigid and intensive in nature. In a study of the Azrin and Foxx 

method, some children initially reacted negatively to timed toilet training by having temper 

tantrums when training was initiated.9 The authors noted this reluctance was overcome by 

providing immediate graduated guidance when a child did not respond to a toilet training step. 

Operant conditioning. While the child-oriented and Azrin and Foxx method incorporate operant 

conditioning, basic operant conditioning techniques have been used to toilet train.11 The goal of 

operant conditioning is to establish habits and proper behavior through positive reinforcement 

with rewards.12 Common rewards for successfully eliminating in the toilet include parental 

affection, toys, and candy. Accidents can be negatively reinforced, often through punishment or 

a lack of positive attention. 

Assisted infant toilet training. This toilet training method is used in China, India, Africa, South 

America, Central America, and parts of Europe; however, it is poorly researched.13 Assisted 

infant toilet training results in infants that are toilet trained at a young age. Simultaneous training 

of bowel and bladder control may begin between the ages of 2 and 3 weeks.5

 When the infant has 

consumed a large meal or shows signs of eliminating, the infant is placed on the toilet or in a 

voiding position.14 The parent must learn the infant’s elimination signals.13 For this reason, this 
12

method has been criticized as the “parent training” method, as the parents must be trained to 

recognize and understand their child’s cues to eliminate. 

When the infant is likely to void, he is placed in a special position and the parent makes a 

noise that the infant learns to associate with voiding. When the infant voids to the specific noise, 

he is rewarded, often with food or affection.5

 As the infant is conditioned, he is expected to better 

communicate his need to void and to crawl on the parent to assume the voiding position. With 

the exception of positioning, the same process is used for bowel training. During the first year of 

life, infants are not punished for having an accident. 

A second method used to train infants is a three-phase approach that establishes a 

relationship with the infant and the potty.15 During the first phase, the parent identifies the 

child’s body signals associated with eliminating. When the infant is expected to eliminate, the 

parent directs the infant’s attention towards the potty and the infant is placed on the potty. 

Eliminations within three minutes of being placed on the potty are positively reinforced. In the 

second phase the infants try to reach or grab the potty prior to being seated on it. The third phase 

establishes unprompted reaching for the potty prior to elimination. 

Elimination communication. Recently, Western countries have witnessed an increased 

enthusiasm regarding toilet training infants. While similar to the assisted infant toilet training 

method used in Africa, elimination communication requires parents to learn to recognize their 

infant’s body language, noises, and bowel and bladder rhythms to determine when the infant is 

about to eliminate. The infant is then placed over the sink, toilet, or a specially designed 

miniature potty and the parent makes sound similar to that of running water. It is recommended 

this method be started at birth. 

Since 2005, many prominent North American newspapers and magazines have published 

articles describing and promoting elimination communication. The main cited benefits of this 

method are reduced diaper expenses, fewer disposable diapers polluting the environment, 

strengthened infant-parent bonds, and increased infant comfort. In addition to articles in the New 

York Times, Boston Globe, National Post, and People magazine, there are also a number of Web 

sites and internet message boards promoting elimination communication 

(www.diaperfreebaby.org; http://www.timl.com/ipt/; http://www.theecstore.com; 

http://www.natural-wisdom.com). The articles are anecdotal and feature testimonials by parents; 

they are not supported by references to research assessing the effectiveness of the methods 

described. 

Current Recommendations 

The American Academy of Pediatrics and the Canadian Paediatric Society have published 

similar toilet training guidelines. Despite the lack of empirical evidences supporting the toilet 

training approach, both guidelines recommend: 1) a child-oriented approach; 2) that children are 

not physically ready to begin toilet training until 18 months of age; and 3) that the child displays 

interest in the process. They also promote the use of a potty chair. Potty chairs can either be 

inserted into the toilet to create a smaller seat or be a small toilet for the child; they may help 

curb the fear of falling into the toilet. The Canadian Paediatric Society also recommends using a 

footstool to make toilet training more comfortable and make the child feel more secure and 

stable. Both guidelines state that toilet training is not a cookie-cutter process and must be adapted 

to the specific child. 
13

American Academy of Pediatrics (AAP). The AAP guidelines strongly suggest a childoriented approach to toilet training and that parents do not pursue toilet training until the child is 

behaviorally, developmentally, and emotionally ready to begin.16 The guidelines recommend that 

parents and pediatricians discuss toilet training methods and expectations at the child’s 12- to 18-

month visits. At the 2-year visit, the pediatrician is able to assess the readiness of the child and 

parents. 

The first step of toilet training is to introduce the potty chair and allow the child to sit on it 

while fully dressed. The parents should make the potty chair constantly available, but not 

pressure the child into acknowledging or using it. Parents can also explain the purpose of the 

potty chair by placing stool in the potty. It is then recommended that the child be placed on the 

potty chair during the specific times when voiding is expected and the parent explains what is 

happening. Positive reinforcement should be delivered after successful use of the potty chair. If 

the child is not successful at toilet training and if the parent-child relationship is not secure, the 

guidelines recommend temporarily abandoning toilet training and focusing on repairing the 

parent-child relationship by partaking in enjoyable activities and re-establishing trust and 

cooperation. It may take several months or years to develop nighttime bladder and bowel control. 

If the child is school-aged and regularly wets the bed, professional assistance should be sought. 

Canadian Pediatric Society (CPS). The CPS guidelines recommend a child-oriented toilet 

training method where the parents and caregivers set time aside for the process.17 The guidelines 

emphasize that there is no correct chronological age when toilet training should begin and that it 

may take several months or years to establish nocturnal continence. 

At the child’s 1-year visit, the physician should begin to educate the parent about the toilet 

training process and readiness should be assessed at approximately 18 months of age. Signs of 

readiness include: walking to the toilet, sitting stably on the toilet, remaining dry for several 

hours, following simple instructions, communicating the need to void, wanting to please parents 

or caregivers, and wanting to be toilet trained. After the child has expressed signs of toilet 

training readiness, the child should be placed on the potty chair while fully clothed. The child is 

then placed on the potty after voiding, followed by sitting on the potty for several minutes 

throughout the course of the day. Next, the child is put on the potty at specific times, such as 

upon waking, after meals, and before sleeping. At each stage, the child should be positively 

reinforced with encouragement and support as opposed to material rewards. Accidents should be 

handled in a supportive and patient manner. 

If toilet training fails, it is most likely due to the child not being psychologically ready for 

training. The child should be returned to diapers for 1 to 3 months before toilet training is reinitiated. It is suggested that parents seek assistance from a general or developmental pediatrician 

if repeated attempts have failed or the child continues to resist training by age 4. 

Factors Related to Toilet Training 

A variety of factors may effect a child’s training. Current clinical practice guidelines stress 

that children can be trained differently and that training methods should be adapted to each child. 

Some of the factors that impact toilet training include sex, age at initiation, culture, race, physical 

or mental handicaps, and previous toilet training attempts. 
14

Sex. While boys and girls often show toilet readiness behavior at a similar age, it has been shown 

that girls begin and complete toilet training earlier than boys.18 19Schum et al. examined 267 

children and found that girls and boys mastered toileting skills in a similar sequence; however, 

girls routinely mastered toilet training skills at a younger age.20 It has been hypothesized that 

girls accomplish this task sooner because of reasons related to socialization and a desire to please 

parents. Also, girls are physically more mature than boys and have more advanced language 

skills, skills that ease toilet training.20 Furthermore, boys may have the additional obstacle of 

learning to adopt separate postures for voiding and defecating. 

Age at initiation. Parents are often unsure of what age to begin toilet training. Parents may over 

or underestimate the skill required to successfully complete toilet training; this may result in 

early or delayed toilet training and associated problems.

Over the last 30 to 60 years, the average age of initiating and completing toilet training has 

risen.1 21 Schum et al. conducted a literature review and found that children toilet trained in the 

late 1990s achieved bowel and bladder control approximately 12 to 15 months later than children 

trained in the 1950s (36 to 39 months versus 24 months, respectively).20 An increased 

understanding of pediatric physiological development may partially account for this trend. Other 

hypothesized explanations include an increased reliance on diapers and the parents’ perception 

that their child is too young to train, especially as the child-oriented approach is promoted.18

Delays in toilet training can result in an increased risk of infectious diseases spread by diarrhea 

and fecal contact among childcare facilities,22 and family stress, particularly as the child 

approaches kindergarten. 

Recommendations suggest that a child be at least 18 months old before commencing toilet 

training.3

 However, Schum et al. have suggested that toilet training readiness skills are not 

obtained until after the child’s second birthday.20 The authors determined that of 267 children, 

girls mastered only 2 of 11 toilet readiness skills by 24 months and boys were not proficient at 

any of the 11 skills until after their second birthday. Schum et al. found the median age for girls 

to commence toilet training was 25.5 months and for boys 30.5 months.18 They recommend that 

toilet training commence when a child is 22 to 30 months old.18

In a cohort of 378 children, Blum et al. found that toilet training was completed at a mean of 

36.8 (range 22 to 54 months).21 Late toilet training (at least 42 months of age) was associated 

with a later mean age of initiating toilet training, lower language score at 18 months, stool 

toileting refusal, increased constipation, and hiding during toilet training. In a second study 

examining the same cohort of children, Blum et al. concluded that training children at a younger 

age, that is, between the ages of 18 and 26 months, resulted in a longer training duration; 

however, there were no adverse events (constipation, stool toileting refusal, stool withholding, or 

hiding during training) associated with early training.19

Constipation. Constipation has a reported prevalence in young children ranging from 0.3 to 28 

percent.23 24 In a retrospective chart review, Loening-Baucke found the prevalence of 

constipation in 4157 children of two years of age to be 4.5 percent. The prevalence in the first 

year of life was 2.9 percent and 10.1 percent in the second year. Partin found that the majority of 

constipated school-aged children presented with pain, impaction and severe withholding and 

recommended treating constipation in infancy in hopes to reduce the likelihood of developing 

chronic fecal impaction and soiling on older children.25
15

Pediatric gastroenterologists from the North American Society of Gastroenterology and 

Nutrition define constipation as a “delay or difficulty in defecation, present for two or more 

weeks and sufficient to cause significant distress to the child.”26 An international group of 

pediatric gastroenterologists defined functional constipation in infants and preschool children as 

“at least two weeks of hard, pebble-like stools for most stools, or firm stools two or fewer times 

per week, in the absence of structural, endocrine, or metabolic disease.” This definition is known 

as the ROME II criteria.27

Being constipated can make defecation painful, and this may be one reason a child may resist 

toilet training and passing a stool. If a child passes a hard stool that causes difficulty or even an 

anal fissure, he suddenly feels unexpected pain. Fear of recurrence may make a child unwilling 

to try a new way of defecating (i.e. in a potty), and the child will continue to stool in diapers or 

pants. Since only the child can feel the urge and initiate defecation, the training method needs to 

be sensitive to the child’s feelings and perceptions of the act.28 Signs and symptoms of 

constipation include a reduced frequency of bowel movements (generally abnormal to have 

fewer than three bowel movements a week29), hard consistency, presence of pain, stool 

withholding, blood while defecating, and the presence of rectal impaction or abdominal fecal 

mass. Blum reported that constipation contributes to stool toileting refusal, rather than being a 

result of it.21 

Culture. Toilet training is approached differently among various cultures. For example, cultures 

that depend on disposable diapers tend to toilet train children at a later age. It has been suggested 

that the increased availability of disposable diapers has been linked to a delay in toilet training.1 

Abramovitch (2000) interviewed mothers in one of three Israeli ethnic groups: Moroccan, 

Kurdish, or Ashkenazi.30 Moroccan and Kurdish mothers tended to begin toilet training at a 

younger age than Ashkenazi mothers (Moroccans at 1.19 years and Kurdish at 1.28 years versus 

1.92 years by Ashkenazi mothers). The methods employed for toilet training were also different; 

Moroccan and Kurdish mothers adopted an early, permissive, symbiotic style, whereas 

Ashkenazi mothers practiced a strict toddler style that may be authoritarian in nature. Moroccan 

and Kurdish children were more likely to develop enuresis than their Ashkenazi counterparts. 

Race and culture. Age at initiation and completion of toilet training appears to be partially 

explained by race. The Digo people of East Africa begin toilet training within the first few weeks 

of life and expect the infant to be reasonably well trained between the ages of four to six 

months.5

 Compared to other races, African-American children were found to start and complete 

toilet training at an early age.18 African-American children began toilet training at median of 21 

months of age and were trained by 30 months. In contrast, Caucasian children commenced toilet 

training at 30 months and were trained at 39 months of age. When surveyed, 50 percent of 

African-Americans felt it was important their child be toilet trained by the age of two, while only 

4 percent of Caucasian parents agreed with the statement. A second study surveyed four cultural 

groups in the United States to determine their beliefs regarding healthy infant and child 

development.31 European American mothers stated children were toilet trainable at 28.1 months 

of age, where as Puerto Rican, African-American, and West Indian-Caribbean mothers felt 

children reached toilet training age between 20.2 to 22.2 months. 

Physical, mental, behavioral, and developmental handicap(s). Toilet training children with 

mental or physical handicaps present its own unique set of challenges. Compared to toilet 
16

training healthy children, there are additional components that need to be taken into 

consideration, such as communication delays, sensory process difficulties, sensitivity to 

stimulation, limited ability to imitate, compromised motor planning, and preference for routine.32 

The CPS guidelines recommend that prior to toilet training, parents have their child assessed 

by a pediatrician to determine the obstacles associated with training a child with special needs.17

The CPS also calls for a comprehensive study to examine the effects and challenges of toilet 

training children with special needs. 

Physical and mental handicaps such as Hirschsprung’s disease, anal atresia, spina bifida, and 

mental retardation, may hamper toilet training. Communication may be an obstacle, particularity 

among children with mental handicaps. When a child has impaired communication skills, 

determining the child’s readiness to toilet train is more difficult. Azrin and Foxx’s toilet training 

method was first tested in severely retarded adults and after proving successful, was adapted to 

children.3

 Several researchers have hypothesized that toilet training will be less successful 

among children with delayed cognitive development; however, this association has not been 

consistently shown. Schum et al. found that cognitive development was not related to success of 

toilet training; however, children attending a program for the developmentally delayed were 

excluded from the cohort.18

Also, children with behavioral and developmental problems such as autism33 or pervasive 

developmental disorder34 may experience difficulty mastering toileting. Toilet training children 

with behavioral and developmental disorders is poorly researched and recommendations are not 

evidence based.

Previous attempts. Regression is a common component of toilet training and it is important for 

the parents not to appear anxious or disappointed and reflect this anxiety onto the child.16 If a 

child’s toilet training regresses, the general advice is to abort toilet training and begin again in 

three months. This may remove barriers in the parent-child power struggle. Also, toilet training 

should not be initiated during a stressful time of a child’s life, such as birth of a sibling, moving, 

or parental divorce. 

Adverse Outcomes During Toilet Training 

While the majority of children are toilet trained without incident, approximately 2-3 percent 

experience an adverse outcome. Five common problems involving elimination behaviors 

encountered during the toilet training period are enuresis, encopresis, stool toileting refusal, stool 

withholding, and hiding while defecating.35 A sixth potential problem may be psychological 

consequences; however, there are no studies that investigate this. 

Enuresis. Initially enuresis simply meant wetting and nocturnal enuresis was bedwetting. Each 

were thought to be psychiatric conditions and as such definitions were created in the Diagnostic 

and Statistical Manual. The Diagnostic and Statistical Manual (DSM) IV-TR defines enuresis as 

1) the repeated voiding of urine into bed or clothes (whether involuntary or intentional); 

2) the behavior manifests twice a week for at least 3 consecutive months or there is the 

presence of clinically significant distress or impairment in social, academic 

(occupational), or other important areas of functioning; 

3) the chronological age is at least 5 years (or the equivalent developmental level); and 
17

4) the behavior is not due exclusively to the direct physiological effect of a substance 

(e.g., diuretics) or a general medical condition (e.g., diabetes, spina bifida, a seizure 

disorder).36

New theories developed regarding the pathophysiology of nocturnal enuresis which included 

the presence of nocturnal polyuria versus uninhibited bladder contractions. Physicians then 

considered two pathological conditions involving wetting which included enuresis meaning day 

and night wetting, or nocturnal enuresis which was simply night wetting. Most of the current 

literature is written reflecting this. Enuresis is further divided into primary or secondary 

enuresis. Primary enuresis occurs when a child has not achieved urinary continence by 5 years of 

age. Secondary enuresis occurs when a child who has achieved bladder control regresses to 

urinary incontinence. The International Children’s Continence Society is considering new 

definitions to better define these terms and improve consistency in publications however in 

writing this review we rely on older terminology which is potentially flawed. There is also 

literature that suggests that some children thought to suffer from simple nocturnal enuresis may 

in fact have daytime symptoms which have not been identified. It is possible that toilet training 

methods may impact this complicated and not well understood pathophysiologic condition.37

Permissive and coercive toilet training methods have been associated with the development 

of enuresis in the literature.8 30 There are a variety of treatment options for enuresis, including 

behavioral, physical, and pharmacological interventions.38 39

Encopresis. Encopresis was also initially thought to be psychological and as such was given a 

DSM diagnosis. To be diagnosed with encopresis, a child must meet the following DSM IV-TR 

criteria: 

1) repeated passage of feces into inappropriate places (e.g., clothing or floor) whether 

involuntary or intentional;

2) at least one such event a month for at least 3 months;

3) chronological age is at least 4 years (or equivalent developmental level);

4) behavior is not due exclusively to the direct physiological effects of a substance (e.g., 

laxatives) or a general medical condition except through a mechanism involving 

constipation (http://www.psychiatryonline.com/content.aspx?aID=8096).

As with enuresis there are likely many factors which lead to encopresis and toilet training 

may be a component. Encopresis can also exist as a primary or secondary condition. Fishman et 

al. examined encopretic children and found that interrupted toilet training and punishment were 

associated with primary encopresis rather than secondary encopresis (50 percent versus 23 

percent and 52 percent versus 26 percent respectively).40 Encopresis can occur with or without 

constipation and overflow incontinence. Encopresis with constipation and overflow incontinence 

is characterized by the passing of loose stool that may include leakage varying in frequency, and 

it is most likely to occur during the day. Encopresis without constipation and overflow 

incontinence is sometimes associated with oppositional defiant disorder and conduct disorder 

(http://www.psychiatryonline.com/content.aspx?aID=8096 ).36 

Stool toileting refusal (STR). There are conflicting beliefs regarding whether children master 

bowel control prior to or simultaneously with bladder control.8 41 STR occurs when the child is 

trained to urinate in the toilet but refuses to defecate in the toilet for a period of at least 1 month. 
18

In a study conducted in a single suburban pediatric practice, researchers reported that 20 percent 

of children suffered from STR.41 There was a significant association between STR and training 

at a later age, having younger siblings, and the parents’ inability to set limits.41 In addition, 

children with STR are more likely to withhold stool and develop primary encopresis.41 42 In a 

recent study, children who resolve STR are not at a higher risk for developing secondary 

encopresis.41 In a case-control study that examined whether children with behavioral problems 

were more likely to exhibit STR, Blum et al. found that oppositional and noncompliant behaviors 

were not associated with STR. They found that children with STR tended to be constipated and 

have painful bowel movements and recommended dietary changes or stool softening medications 

in the treatment of STR. In general, many parents do not perceive STR to be problematic and 

believe that it frequently resolves on its own.41 43 

There has been one RCT that examined an intervention to prevent STR.44 Taubman et al. 

enrolled children in an RCT between the ages of 17-19 months of age. Children randomized to 

the treatment group received a three-prong intervention consisting of: 1) child-oriented toilet 

training guidelines, 2) parents only use positive words when referring to feces; and, 3) prior to 

toilet training, parents praise their child for defecating in their diaper. Children randomized to the 

control group received the same toilet training guidelines as the intervention group. While there 

was no difference in the incidence of STR between groups, the duration of STR and time to 

complete toilet training were significantly less among children in the intervention group. 

Stool withholding. Stool withholding refers to any physical maneuvers a child may perform in 

an effort to avoid defecating.14 These acts include doing a “potty dance,” running, or crossing 

one’s legs. Stool withholding can result in constipation because it often involves contracting the 

perineal muscles while the bladder and rectum are constricting. 

Of 29 parents who sought medical intervention for STR, 23 cited “severe stool withholding” 

as the reason for requesting an intervention.41 The most common intervention was to return the 

child to diapers. Stool withholding may be further complicated if parents misinterpret stool 

withholding behavior as an indication that the child is not able to have a bowel movement.41

Hiding to defecate. Some children will hide from adults while defecating. This phenomenon can 

begin either prior to toilet training or after toilet training has commenced. Some children who 

hide while defecating are able to control when and where they will defecate and chose not to 

utilize the toilet. 

This behavior is not well researched. In a cross-sectional study, Schonwald et al. (2004) 

found that 74 percent of children who had difficulties toilet training hid to defecate. Stool 

withholding is associated with hiding while defecating.45 Taubman et al. compared children who 

hid to those that did not and found that children who hid to stool were more likely to exhibit 

stool toileting refusal, stool withholding, constipation behaviors, and toilet training completion at 

a later age.46 The median age for the onset of hiding to stool was 22 months. While the authors 

were unable to determine why children hid while defecating, they hypothesized that this behavior 

may be in response to embarrassment, fear, or not having observed adults defecating, thus 

assuming it is a private behavior. 
19

Objectives of this Review 

All healthy children and many children with special needs attempt toilet training. During the 

developmental period, the child gains independence while attempting to conform to parental and 

societal expectation and norms. Several societies and organizations have published toilet training 

guidelines (Table 2). 

Table 2. Summary of toilet training guidelines 

Guideline Year Location Recommended Method(s) and Special 

Needs Recommendations 

American Academy of Family 

Physicians

2005 USA Method: Begin when parent and child are 

ready (approximately 2 years). Use childoriented approach, praise successes, do not 

express disappointment at accidents, and 

avoid punishment. 

Special needs: not mentioned 

American Academy of Pediatrics 2000 USA Method: Begin when developmentally ready 

and the child shows signs of readiness 

(approximately 2 years). Use child-oriented 

approach, praise successes with positive 

terminology, and avoid punishment or 

shaming. Make the process positive, natural 

and non-threatening. Do not force child. 

Special needs: not mentioned 

Canadian Paediatric Society 2005 Canada Method: Begin when child is physiologically 

and psychologically ready. Anticipatory 

guidance with child-oriented approach, praise 

successes, and do not punish or use negative 

reinforcement. 

Special needs: Assess readiness and degree 

to which child is hampered with the physician 

involved with care of the special needs child. 

Pampers Parenting Institute 

Pediatric Roundtable 

2006 Method: same recommendations as AAP 

Special needs: not mentioned 

Although all children undergo toilet training, there is limited research that has examined the 

effectiveness of different methods. We were unsuccessful at finding clinical practice guidelines 

published by the following organizations: American Academy of Child and Adolescent 

Psychiatry, American Academy of Neurology, American Pediatric Society, Asian Society for 

Pediatric Research, National Enuresis Society, Society for Developmental and Behavioral 

Pediatrics, and European Society for Pediatric Research. To the best of our knowledge, the 

organizations listed above do not have toilet training clinical practice guidelines. 

Our objective was to systematically gather the existing evidence to determine the optimal 

toilet training method for both healthy children and those with special needs. We assessed which 

toilet training methods best achieved bladder and bowel continence and whether the methods 

were associated with the development of adverse outcomes. The objectives are pictorially 

displayed in Figure 1.
20

Figure 1. Analytical framework for the effectiveness of different methods of toilet training for bowel and bladder control 

•Age •Sex •Culture •Race/ethnicity •Constipation•Age at initiation 

•Stool toileting refusal 

Modifiers 

Healthy Children Toilet Training Methods Bow

CoAdv•Dy•En•En•Laand •Pscon•Ot

1

2 

3

Population Infants and toddlers 

Special Needs •Neuromuscular •Cognitive •Behavioral •Co-morbidities (e.g., autism, ADHD, etc.) 

Toilet Training Methods Bow

Co

Population 4Infants, toddlers, children 
21

Key Questions 

The American Academy of Pediatrics put forth the following four questions: 

1. What is the evidence for effectiveness of various toilet training methods to achieve bowel 

and bladder control? 

2. What factors modify the effectiveness of toilet training, such as age, sex, race, ethnicity, 

culture, age at initiation, constipation, or stool toileting refusal? 

3. What is the evidence for various toilet training methods as a risk factor for adverse 

outcomes, such as dysfunctional voiding, enuresis, encopresis, later problems, and 

psychological consequences? 

4. What is the effectiveness of toilet training methods for achieving bowel and bladder 

control among patients with special needs? 
23 

Chapter 2. Methods 

Methods for the Systematic Review 

Literature Search 

The research librarian, in collaboration with the TEP (Technical Expert Panel), identified 

appropriate electronic databases and developed search strategies tailored to the specific database. 

The search strategies were based on variations of the following keywords and subject headings: 

“toilet training,” “potty training,” and a combination of “toilet” or “potty” with “learning,” 

“conditioning,” “teaching,” “educating,” and “behaviors.”

The search strategies were used to search the following electronic databases: MEDLINE®, 

Ovid MEDLINE® In-Process & Other Non-Indexed Citations, Ovid OLDMEDLINE®, Cochrane 

Central Register of Controlled Trials (which contains the Cochrane Developmental, Psychosocial 

and Learning Problems Group’s specialized register of trials and the Cochrane Incontinence 

Group’s specialized register of trials; these groups hand search journals pertinent to their content 

areas and add relevant trials), EMBASE, CINAHL®, PsycINFO®, ERIC® (Educational 

Resources Information Center), EBM Reviews (Cochrane Database of Systematic Reviews, ACP 

Journal Club, Database of Abstracts of Reviews of Effects), HealthSTAR, AMED (Allied and 

Complementary Medicine), Web of Science® (Science Citation Index Expanded and Social 

Sciences Citation Index), Biological Abstracts, Sociological Abstracts, OCLC ProceedingsFirst, 

OCLC PapersFirst, Dissertation Abstracts, Index to Theses, and the National Research Register’s 

Projects Database. Trials registers (Current Controlled Trials and ClinicalTrials.gov) were 

searched for trials. Position statements by the American Academy of Pediatrics (Web site at 

http://www.aap.org/) and the Canadian Paediatric Society (Web site at http://www.cps.ca/) were 

sought. The NLM Gateway was searched for identification of meeting abstracts. The detailed 

search strategies appear in Appendix A∗. 

In addition to the above search strategy, annual conference proceedings of the American 

Academy of Pediatrics and the Canadian Paediatric Society were hand searched for the years 

2002–2005 inclusive. Also, reference lists were reviewed. Sentinel articles identified by TEP 

members were tracked forward using the Cited Reference Search feature in Web of Science®. 

Selection and Inclusion 

Screening. Once all duplicate references were removed, two reviewers independently screened 

the electronic search output. The title and when available, the abstract were assessed for possible 

inclusion using general inclusion criteria (i.e., was it primary research assessing a toilet training 

method) and classified as “include,” “exclude,” or “unclear.” The full text of all “include” and 

“unclear” studies was obtained and formally assessed for inclusion. 

 

∗

 Appendixes and Evidence Tables are provided electronically at http://www.ahrq.gov/clinic/tp/toilettrtp.htm
24

Inclusion. A priori inclusion criteria were developed (Table 3) and the studies were assessed for 

inclusion using a standardized form (Appendix B). Two reviewers independently applied the 

inclusion criteria and all discrepancies were resolved through discussion or consulting with a 

pediatrician and a pediatric urologist. 

Studies examining the treatment of children with enuresis and/or encopresis were excluded. 

Although treatment components of enuresis and encopresis are similar to toilet training, it was 

believed that an enuretic and/or encopretic child would have already experienced at least one 

method of toilet training. The treatment of enuresis and encopresis was considered to be outside 

the scope of this review and there are several published systematic reviews that address these 

topics. Studies that measured the development of enuresis or encopresis as the result of a specific 

toilet training method were included. 

The studies must have been published in English and all study participants had to be children, 

defined as less than 18 years of age. With the special needs literature, studies have applied toilet 

training methods to both children and adults. If the pediatric and adult data were presented 

separately, the study was included. In addition, the exact condition or diagnosis of special needs 

was not required. For example, studies describing children as “severely retarded” or “profoundly 

retarded” were included. 

A wide spectrum of toilet training programs was included. The study could examine a 

program specifically designed to toilet train children or, for example, an operant conditioning 

program that aimed to change several behaviors. The study was included as long as toileting was 

one of the targeted behaviors and a toileting outcome was measured. 

When it appeared that outcomes on the same or a portion of the same cohort of children were 

reported upon in multiple publications, a primary publication was identified. In general, the 

largest, most recent publication was assigned as the primary publication. If it was unclear if the 

studies reported on discrete children, individual investigators were contacted.

Table 3. Inclusion and exclusion criteria for review on the effectiveness of different methods for bladder and 

bowel control* 

Criterion Toilet Training Review 

Study Design Include: RCT, CCT, prospective or retrospective cohort, case-control, cross-sectional or 

case-series of at least 5 children. 

Exclude: case studies or case-series of <5 children. 

Participants Include: infants, toddlers, or children with or without co-morbidities, neuromuscular, 

cognitive, and/or behavioral disabilities. 

Exclude: children with enuresis or encopresis and adults with special needs. 

Intervention One or more of the following methods: Azrin and Foxx method, child-oriented method, 

operant conditioning, assisted infant toilet training, or any other toilet training program or 

intervention aimed at achieving bladder and/or bowel control. 

Outcome Measures Bladder control, bowel control, successes, failures/accidents, adverse outcomes (e.g.: 

enuresis, encopresis, stool withholding). 

* RCT indicates randomized controlled trial; CCT, controlled clinical trials 
25

Quality Assessment 

Two reviewers independently assessed the methodological quality of the included studies. 

Any discrepancies were resolved through discussion or consulting a third party as needed. The 

reviewers, a pediatrician, and a pediatric urologist developed a priori guidelines regarding the 

interpretation and implementation of the quality tool. If a specific question from the quality 

assessment tool was not applicable to the study design, the question was answered “no.” When 

the same cohort of children was examined in multiple publications, the methodological quality 

was assessed on the primary publication. 

The methodological quality of observational studies was assessed using the Downs and Black 

partially validated “Checklist of the assessment of methodological quality of both randomized 

and non-randomized studies of health care interventions” (Appendix B∗).47 This tool comprises 

six sections that assess reporting (10 questions, total score 11), external validity (three questions, 

total score three), internal validity–bias (seven questions, total score seven), internal validity–

confounding (six questions, total score six), and power (two questions, total score two). A 

maximum score of 29 indicates the highest methodological quality and a score of zero represents 

the poorest methodological quality. The funding source of each study was recorded. 

 The Jadad Scale was used to assess the methodological quality of randomized and nonrandomized controlled clinical trials.48 The Jadad Scale is a validated five-point scale that 

examines the methods of randomization, double-blinding, and the reporting of withdrawals and 

dropouts. In addition, Schultz’s definitions of concealment of allocation were applied and each 

trial was described as “adequate,” “inadequate,” or “unclear.”49 The funding source of each study 

was recorded.

Data Extraction 

The reviewers, a pediatrician and a pediatric urologist, developed and piloted a data 

extraction form (Appendix B). Data were extracted by one reviewer and checked for accuracy 

and completeness by a second. All data were entered into SRS 3.0, a web-based software 

program designed specifically for systematic reviews. Any discrepancies were resolved through 

consensus or consultation with the co-task leaders as required. To facilitate extracting graphical 

data points with the greatest accuracy, graphs were scanned into CorelDraw®. 

Data regarding the study design, toilet training objective (bladder versus bowel and daytime 

versus nighttime), patient demographics, toilet training interventions, and outcomes were 

extracted. Children were described as healthy, mentally handicapped, or physically handicapped. 

Sex, race, culture, socioeconomic status, age of toilet training initiation, and baseline bladder and 

bowel function were extracted. Chronological age and developmental or social ages or both if 

reported were also extracted. Developmental or social age refers to a child’s specific motor and 

mental capabilities. The source of the study population was also recorded. Details concerning the 

toilet training program were documented. The toilet training intervention was classified as Azrin 

and Foxx, child-oriented, operant conditioning, or other. In situations where the toilet training 

method was not specifically called one of the specific methods but was similar, it was classified 

as the specific method. When applicable to the specific toilet training intervention, the frequency 

 

∗

 Appendixes and Evidence Tables are provided electronically at http://www.ahrq.gov/clinic/tp/toilettrtp.htm
26

of accident checks, and toileting was documented. Information on the length of the program, use 

of positive or negative reinforcement, external signaling devices, special toilet training 

equipment, and/or a specific toilet training room was recorded. Any training the parents or 

caregivers received was also recorded. A number of outcomes were extracted, including change 

in bladder and bowel function, number of successes and accidents, success and failure rates, time 

to toilet train, and the occurrence of adverse events (e.g., enuresis, encopresis, stool withholding, 

etc.). Where possible, results were extracted by effect modifiers, such as age or sex. 

Data Analysis 

Due to extreme clinical heterogeneity with respect to study designs, interventions, 

populations, and outcomes, no statistical meta-analysis was performed. Each study was 

organized by population (healthy, mentally handicapped, and physically handicapped) and the 

toilet training program was grouped as Azrin and Foxx (also including modified Azrin and 

Foxx), child-oriented, operant conditioning, and other. Each study was qualitatively summarized 

and the vast majority of this summary was taken directly from studies themselves. However, 

there were a few instances where the authors did not perform a statistical analysis and a Fisher’s 

exact test was used to compute a p-value to compare dichotomous data between two groups. 

There were instances when the data were manipulated. When individual data were presented 

in tabular form, a standard deviation (SD) was calculated. There were situations when the 

baseline characteristics and outcomes were stratified by age or another variable. When possible, 

the data were combined by toilet training program using the following formulas: 

Exposure group mean = 

∑

∑

=

=

k

i

i

k

i

i i

n

n

1

1

μ

 

Exposure group SD = 

n k

n

k

i

i

k

i

i i

−

−

∑

∑

=

=

1

1

2

( )

( 1)σ

When applicable, each study was analyzed with respect to its definition of a child being 

successfully toilet trained and graphical summaries of such information were presented. The 

studies varied in their definitions of success and we attempted to classify the patients in each 

study as to whether they were toilet trained, i.e.: a “success.” Definitions considered equivalent 

to “fully trained” included (among others) self initiated elimination in toilet, daytime continence 

for bowel and bladder, continued absence of wetting or soiling between toileting, and complete 

toileting with no prompts. Definitions that were considered partial successes included (among 

others) one or fewer accidents per month, reduced number of accidental daytime wettings, 

increased toileting in commode, and less than four bladder and two bowel accidents per week. 

Only those studies that reported these numbers and had a well-defined intervention were 

included in the graphs. 
27

Statistical tests were calculated using StatXact (Version 7, Cambridge, USA) while the 

graphs were produced using S-Plus (Version 7.0, Seattle, USA). 

Peer Review 

Fourteen toilet training experts, developmental pediatricians, and methodological experts 

were asked to peer-review the draft of this evidence report. Nine agreed to do so and six 

provided comments within the allocated time period. We reviewed all comments and revised this 

report accordingly. A list of the peer-reviewers appears in Appendix F and is available on the 

AHRQ Web site. 
28 
29 

Chapter 3. Results 

Literature Search 

Database specific search strategies were applied to the electronic databases and output 

generated 1476 unique citations. Five potentially relevant studies were identified by hand 

searching the conference proceedings from the Canadian Paediatric Society and American 

Academy of Pediatrics. In total, 1481 unique studies were reviewed and five were later 

determined to be duplicates. Study identification and selection is outlined in Figure 2. 

Seven hundred and seventy-two studies were identified as being potentially relevant. Studies 

were then excluded for the following reasons: inappropriate study design (n=303), inappropriate 

intervention (n=237), foreign language (n=43), incorrect study population (n=43), or inadequate 

data or outcomes not reported (n=4) (Appendix E∗

). 

 

∗

 Appendixes and Evidence Tables are provided electronically at http://www.ahrq.gov/clinic/tp/toilettrtp.htm

Initial independent 

references from all 

databases 

(n=1,476)

Citations of potential 

relevance 

(n=772)

Second screening 

with specific criteria 

Multiple publications 

(n=6)

Reference lists, 

authors’ lists, 

conference 

presentations 

First screening of titles and 

abstracts using general criteria 

Excluded studies (n=661) 

• Incorrect study design: 303 

• Incorrect intervention: 237 

• Foreign language: 43 

• Incorrect population: 43 

• No outcomes: 4 

Determined to be 

duplicates (n=5) 

Included studies (n=34) 

• Observational studies: 26 

• Trials: 8 

Figure 2. Selection of Included Studies
30

There were several instances where the same cohort children, or a portion of the same cohort, 

was included in more than one publication. In such cases, the most recent and complete study 

was chosen as the primary study and additional information was extracted from the related 

publications. A description of these multiple publications appears in Appendix C. 

Description of Included Studies 

Thirty-five studies were included in this systematic review. There were three instances of 

multiple publications that examined toilet training within the same group of children. 

Observational Studies. The median year of publication was 1976.5. Half of the studies were 

conducted in the United States (13/26; 50 percent), followed by the Netherlands (4/26; 15 

percent). One study was conducted in Japan33, the only study occurring outside of the United 

States or Europe. The median sample size was 34.5; five studies included one hundred or more 

children.1 8 41 50 51 

The included observational studies are described in Appendix D, Evidence Tables D-1, D-2, 

and D-3∗

. Six of the 26 (23 percent) included studies that examined healthy children. Fifty 

percent (13/26) of the studies assessed toilet training methods in children with mental handicaps 

and 5 of the 26 studies examined physically handicapped children. Thirteen of 20 studies stated 

the children’s specific handicap. Three studies included autistic children and two studies 

examined children with spina bifida. Two studies included mixed populations: one was a 

combination of healthy and mentally handicapped children and the other was a combination of 

mentally and physically handicapped children. Children were most commonly recruited from 

special care facilities (13/26; 50 percent), followed by clinical practice (7/26; 27 percent), 

community (2/26; 8 percent), school (2/26; 8 percent), and community and clinical practice 

(1/26; 4 percent). One study did not report the source of the children. 

The goals of the specific toilet training programs were summarized as self-directed daytime 

bladder control (5/26; 19 percent), daytime bowel and bladder control (4/26; 15 percent), 

daytime and nighttime bladder control (2/26; 8 percent), daytime and nighttime bowel control, 

prompted bladder and bowel control anytime (2/26; 18 percent), and self-directed daytime 

bladder and bowel control (2/26; 8 percent). The remaining studies examined a variation of 

daytime versus nighttime, self-directed or promoted, bladder or bowel control. Twenty of the 

included studies examined one toilet training program and the remaining six studies assessed two 

programs, for a total of 32 programs. The most common toilet training program was operant 

conditioning (8/32; 25 percent) and Azrin and Foxx (5/32; 16 percent). Child-oriented toilet 

training was assessed in three studies. The remaining studies examined ‘other’ toilet training 

programs, which often included components of reinforcement and increasing liquids. 

The outcomes were heterogeneous. The primary outcome in 23 of the 26 (88 percent) studies 

measured success or failure of toilet training; however, ‘success’ had variable definitions, such 

as bladder and/or bowel continence, self-toileting, directed toileting, lack of accidents, etc. The 

outcomes assessed in the remaining three studies were lower urinary tract symptoms, enuresis, 

and stool toileting refusal. 

 

∗

 Appendixes and Evidence Tables are provided electronically at http://www.ahrq.gov/clinic/tp/toilettrtp.htm
31

Trials. In this review, there were 13 trials that examined eight unique cohorts of children 

(Appendix D Evidence Table D-4, D-5, and D-6). The median year of publication was 1977 and 

only three of the eight (38 percent) trials were conducted after 199144 52 53. Six trials were 

conducted in the United States (75 percent) and one of each in the United Kingdom (13 

percent)53 and Netherlands (13 percent)52. The median sample size was 22.5 children; two trials 

included more than 50 children (25 percent).44 54 All eight trials employed a parallel arm study 

design. Three trials had three arms (38 percent)53 55 56; the five remaining trials were two-armed. 

The included populations were heterogeneous. Three of the trials included healthy children 

(38 percent), four included children with a mental handicap (50 percent); and one trial included 

children with Hirschsprung’s disease (13 percent). All of the mentally handicapped children 

were recruited from a special care facility. Taubman et al. enrolled children from their clinical 

practice, while the remaining studies recruited children from the community. 

The included trials had a range of toilet training objectives: mastery of daytime and nighttime 

bladder control (2/8; 25 percent), daytime bladder control (2/8; 25 percent), and self-directed 

daytime bladder control (2/8; 25 percent), self-directed and prompted daytime bladder control 

(1/8;l 13 percent), and self-directed daytime bladder and bowel control (1/8; 13 percent). The 

toilet training methods were diverse. Azrin and Foxx was the most common method and it was 

examined in at least one arm of four of the trials. In two trials, variations of the Azrin and Foxx 

method were compared to one another. The remaining trials used other toilet training methods, 

such as Spock’s baby book54, relaxation-tension exercise regimen57, operant conditioning55, 

praising defecation44, and a biopsychosocial approach aimed to reduce defecation associated 

anxiety and stool avoidance. Two trials contained a control group that was comprised of no toilet 

trainng method (2/8; 25 percent).55 56

Seven of the included eight studies measured a variation of toileting accidents or successes, 

such as the frequency or number of accidents/successes or proper use of the toilet. One study 

measured the development of stool toileting refusal.44

Methodological Quality of Included Studies 

Observational Studies. The mean Downs and Black score of the 26 included observational 

studies was 17.2 (SD 2.8) of a maximum possible score of 29. The mean scores of the individual 

components of the quality tool are presented in Table 4 and additional details are reported in 

Appendix D Evidence Table D-7∗

. 

Table 4. Summary of components of Downs and Black Score 

Reporting External 

Validity Bias Confounding Power Overall 

Maximum 

Score 

11 3 7 6 2 29 

Mean Score 

(SD)* 8.1 (1.3) 1.3 (1.1) 4.2 (0.8) 3.0 (1.0) 0.5 (0.5) 17.2 (2.8) 

*

SD indicates standard deviation

 

∗

 Appendixes and Evidence Tables are provided electronically at http://www.ahrq.gov/clinic/tp/toilettrtp.htm
32

The majority of the studies collected data prospectively (14/26; 54 percent). Seven studies 

(27 percent) reported their funding source: government agency (1/26; 4 percent), private industry 

(1/26; 4 percent), foundation (1/26; 4 percent), combination of government and foundation (1/26; 

4 percent), or other (3/26; 12 percent). 

 

Trials. The methodological quality among the included studies was very similar. With the 

exception of one trial52, all of the trials scored two on the Jadad scale. The two points were 

earned for stating the trial was randomized and adequately describing the children who withdrew 

or dropped out from the trial. Van Kuyk (2001) was a clinical controlled trial, but not 

randomized and scored 1 on the Jadad scale.52 All trials failed to describe the method used to 

conceal allocation. Four of the trials were funded by government organizations (50 percent) and 

one received funding from an internal source (13 percent); the remaining three trials did not 

comment on funding source (38 percent). Appendix D Evidence Table D-8 provides additional 

information about the methodological quality of the included trials.

Toilet Training Success 

Toilet training successes are displayed pictorially in Figures 2 to 4. The arms of all the 

studies reporting success rates are presented by the type of toilet training method, study design, 

and healthy versus handicapped child. Because the studies are heterogeneous with respect to 

toilet training definitions, type of children (even within the broad categories of healthy, 

physically and mentally handicapped), and intervention (even within the categorizations) these 

comparisons are meant only for broad illustrative purposes and can not be used to compare the 

toilet training methods to one another. In addition, the findings of the individual studies are 

described in Appendix D Evidence Table D-9 and D-10∗

. 

Figure 3 shows, perhaps not surprisingly, that healthy children tended to have the highest 

success rates, generally ranging from 80 to 100 percent. There was only one small study that had 

a lower success rate and the children were toilet trained by the Azrin and Foxx method. Studies 

conducted with healthy children tended to be a mix of RCTs, and both prospective and 

retrospective cohorts. 

The studies examining mentally handicapped children were all relatively small and generally 

prospective in nature. Success rates encompassed the full spectrum from 0 to 100 percent; the 

operant conditioning method results were particular dispersed (Figure 4). 

The studies assessing physically handicapped children primarily used toilet training methods 

categorized as “other” with the exception of one small study that examined operant conditioning 

(Figure 5). Similar to studies of mentally handicapped children, success rates were variable, 

ranging from 15 to 100 percent, although the majority of studies and the larger ones had rates 

under 50 percent. 

 

Direct Comparisons 

Healthy children. There were four studies that examined head-to-head comparisons between 

methods among normal children. 

 

∗

 Appendixes and Evidence Tables are provided electronically at http://www.ahrq.gov/clinic/tp/toilettrtp.htm
33

Matson randomized ten children (age 20 to 26 months) into one of the following groups: 

Azrin and Foxx method with an experienced trainer or mothers training their children using a 

book to guide the toilet training process.58 Four out of five children in the former group were 

successfully trained, while only one of five in the latter group was completely successful, one 

obtained partial success, the remaining three failed. The small sample size precludes statistical 

significance and would in even the most extreme case (80 percent success rate versus 20 percent 

success rate; p-value for Fisher’s exact test (2 sided): 0.21). 

The Azrin and Foxx method was also used in an RCT conducted by Candelora (1977) to 

compare it to the Spock method in 71 healthy children aged 18 to 35 months.54 Three primary 

outcomes were examined: number of accidents, number of successes, and number of wet 

mornings. Three time periods were examined: pre-treatment, post-treatment, and at follow-up. 

When looking at difference in pre-training and post-training results as well as in pre-training and 

follow-up results, the Azrin and Foxx method was found to be superior to the Spock method in 

all three outcomes. However, there was no significant difference between the groups with respect 

to post-training and follow up. Using the Azrin and Foxx method, the number of accidents per 

child per day was reduced by 2.48 from pre-training to post-training under the Azrin and Foxx 

method and reduced an additional 0.70 at follow-up, resulting in a total reduction of 3.17. For the 

Spock method, there was a reduction of 1.37 in post-training and an additional 0.52 at follow up 

(1.90 total reduction). The number of successes per child per day was increased by 2.50 in posttraining and by an additional 0.87 at follow-up, for a total increase of 3.37 when using the Azrin 

and Foxx method. For children trained using the Spock method, there was an increase of 1.12 in 

post-training and an additional 0.79 in follow-up (1.90 total increase). Finally, the percentage of 

mornings wet was reduced in the Azrin and Foxx group by 21 percentage points in post-training 

and an additional 10 points in follow-up (total of 31 percentage points), compared to a reduction 

in the Spock method of 6 percentage points in post-training and an additional 9 points at followup, for a total reduction of 15 percentage points. 

Taubman enrolled 406 children aged 17 to 19 months in a toilet training study using a childoriented approach, and the parents determined when toilet training would commence. The 

children were randomized into two groups: one group was given instructions to avoid negative 

terms to describe defecation or to a group who received no such direction.44 The groups were 

equivalent in terms of number of children with stool toileting refusal (STR) (26 percent in the 

intervention group compared to 23 percent in the control group) but duration of STR was 

significantly longer in the control group (7.3 months compared to 5.1 months; p=0.03). No 

significant differences were found between the groups in terms of incidence of stool withholding 

(intervention 52 percent; control 55 percent) or incidence of hiding during defecation 

(intervention 68 percent; control 70 percent). The intervention group did find that toilet training 

was completed significantly sooner (intervention 40 months; control 43 months; p=0.04). 

Bakker conducted a retrospective study that collected data on 4332 primary school age 

children and compared children who did and did not develop abnormal outcomes in bladder 

control.59 There were 3404 children in the control group and 928 in the symptom group. The 

authors found that significantly more children in the control group had prompting from their 

parents during toilet training than those in the symptom group (68 percent versus 62 percent; p < 

0.001). Parents of the symptom group tended to reward and punish more so than the control 

group (53 percent versus 46 percent). Parents reacted differently when an attempt to void was 

unsuccessful. Parents in the control group were much more likely to encourage the child to try 

again later (83 percent compared to 67 percent; p < 0.001). Those in the symptom group were 
34

more likely to make the child wait until voiding (8 percent to 3 percent; p < 0.001), make the 

child push or strain (13 percent to 5 percent; p < 0.001), make special noises (43 percent to 37 

percent; p =0.002), and open a tap (26 percent to 21 percent; p=0.003). 

Mentally handicapped children. There were eight studies that contained direct comparisons of 

interventions in mentally handicapped children: four were RCTs, two were multiple cohort 

studies, while the remaining two were single cohort studies. 

Smith conducted an RCT to look at three methods of training fifteen severely mentally 

retarded children with social ages ranging from 0.94 to 2.2 years on the VSMS scale.60 The first 

method was an intensive individual regular “potting” program, the second was group training 

with regular “potting” program and the third was an intensive individual timing training 

program. The primary difference between regular “potting” and timing training is in which the 

manner incontinent events are handled. In the timing training method, the child is promoted to 

toilet and positively reinforced for urinating after an incontinent event. An incontinent event 

among the regular “potting” group resulted in a reprimand and 10 minute timeout. The number 

of children who achieved independent toileting at the end of training was 5/5 in the first method, 

1/5 in the second method, and 4/5 in the third method. Despite the small sample sizes, the exact 

three-way test for independence is approaching significance (p=0.051). In addition, the 

comparison of method 1 versus 2 does show a significantly greater odds of being trained in 

group 1 (Fisher exact p-value=0.048). Looking at percentage reduction in incontinence and the 

end of the 12-week study, methods 1 and 3 (about 97 percent and 80 percent respectively) did 

achieve greater reductions than method 2 (about 45 percent), although the difference was not 

significant (F p-value=0.10). The authors competed a 10-year follow-up study.53 Only one child 

(in method 1) was still independent after 10 years. The authors also examined incontinence 

reduction both after the initial study and at the 10-year follow-up, although no comparisons 

among groups were presented. The first method showed a 99 percent reduction in incontinence 

after initial training and this dropped to 88 percent after 10 years. For the second method, 

incontinence was initially 39 percent and improved to 52 percent after 10 years. For the third 

method, incontinence decreased from 80 percent to 74 percent after 10 years. 

Edgar completed an RCT of 20 severely and profoundly retarded children (developmental 

ages between 15 and 23 months) to examine relaxation methods versus a control group.57 Among 

the children who received relaxation exercises, there was a significant reduction in accidents and 

toilet training was successful (8/10 versus 2/10; p=0.02). Self-initiated toileting was identical in 

the two groups: two children from each group eventually achieved it. Compared to the control 

group, the relaxation group also showed significant reduction in accidental urination and 

improvement in appropriate urination. 

Hundziak randomized 29 severely mentally retarded boys with a social quotient between 8 

and 33 months to one of three interventions: operant conditioning, conventional training, or a 

control group.55 Scores for defecation and urination in toilet were determined and non-parametric 

tests conducted. The operant conditioning group advanced significantly more in both defecation 

and urination than the conventional training group, and more in defecation (although not in 

urination) than the control group. There were no significant differences between the conventional 

and control groups. The authors concluded that the operant conditioning method is useful in 

training severely retarded children. 

Sadler conducted an RCT among 14 severely retarded children aged 7 to 12 years.56 Children 

were randomized to Azrin and Foxx method, a no training group, or a scheduling toilet training 
35

method. The primary outcome was the number of accidental urine-dampened pants and was 

analyzed using a repeated measures ANOVA while controlling for time. Compared to both the 

no-training group and the scheduling method, the Azrin and Foxx method proved to significantly 

reduce dampened pants (3 months and 4 months, p < 0.01 in all comparisons). As the experiment 

continued to its second phase, the scheduling group and half the no-training group were moved 

to the Azrin and Foxx group, which had a significantly lower number of dampened pants than 

the remaining no-training group (p < 0.01). 

Kimbrell examined 40 severely retarded female children (VSMS range 6 to 28 months).61

Based on age, race, length of institutionalization and VSMS, children were systematically 

allocated to an operant conditioning behavior modification intervention or a control group. 

Compared to children in the control group, the children receiving operant conditioning had 

significantly greater gains in the toilet training score component of the VSMS (gain of 4.10 

versus 0.30, p < 0.001). 

Tierney studied 36 mentally subnormal children with mental ages between 4 and 22 

months.62 Age, mental age, level of functioning, degree of incontinence, and degree of mobility 

were used to systematically separate the children into an operant conditioning behavior 

modification group and a control group. Seven patients in the operant conditioning group 

achieved consistent continence while an additional seven showed a marked improvement. The 

remaining four patients failed to improve. None of the eighteen control patients improved. The 

differences in both achievement of consistent continence and improved continence were 

significant (Fisher’s exact test: p < 0.0001 and p=0.008 respectively). 

Connolly looked at nine children between the ages of 3 and 18 years that exhibited moderate 

to severe mental handicaps.63 Four children who were already toilet trained were included as 

controls. The toilet training program consisted of a three-stage operant conditioning process that 

involved both positive and negative reinforcement. The amount of soiling and wetting from 

baseline to program completion improved by 15.8 percent and 75.0 percent respectively. 

Improvements were still evident at the six-week follow-up; however, they had decreased to 14.0 

percent and 25.0 percent respectively. Two of the nine children were considered fully trained. 

Lancioni describes two separate experiments on toilet training autistic, retarded children.64

The first looked at 5 children (aged 10.6 to 14.6 years) that were divided into two similar 

interventions. For the 3 children assigned to intervention A, 25 potties were placed throughout 

the room and there were no potties placed in the room for the 2 children in intervention B. The 

other aspects of the toilet training program were identical. All three subjects in A showed 

independent toileting, while neither of the two subjects in B did. For the second phase of the 

study the two B children were transferred to intervention A and achieved independent toileting. 

The second study was almost identical in design to the first with the exception that no negative 

reinforcement was employed. Four children (ages 11.0 to 13.8 years) were put into the two 

interventions A and B (two in each intervention). Once again the subjects in A exhibited 

independent toileting, while those in B did not until moved into intervention A for the second 

phase. The authors conclude that intervention A, with or without negative reinforcement, is 

effective in promoting independent toileting for autistic, retarded children. 

Physically handicapped children. There was only one study that contained direct comparisons 

of interventions involving physically handicapped children. Van Kuyk (2001) randomized 27 

children (aged 2 to 12 years) with Hirschsprung’s disease to either a multidisciplinary behavior 

treatment or a waiting list control.52 An ANOVA was performed on the change scores for six 
36

different outcomes and the intervention group was found to be significantly superior to the 

control group in all outcomes. There were three scores used to measure toileting: the Templeton 

score (intervention: 1.1 reduction; control: 0.0 reduction), the Wingspread score (intervention: 

1.3 reduction; control: 0.1 reduction) and the Wingspread constipation score (intervention 0.7 

reduction; control: 0.1 reduction). The remaining three outcomes were percent of feces in toilet 

(intervention: 53.7 percent increase; control: 2.3 percent decrease; p<0.001), number of days 

without soiling (intervention: 8.4 day increase; control: 0.7 day increase; p<0.001), and scale 

determining parental judgment incontinence (intervention: 5.2 reduction; control: 0.9 reduction; 

p<0.05). 

Single Cohorts 

Healthy children. Five studies examined toilet training in healthy children: three studies 

assessed a child-oriented approach and the remaining two evaluated Azrin and Foxx methods. 

Three studies examined the child-oriented approach to toilet training. Stool toileting refusal 

of at least one month duration occurred in 22 percent of the children (106/482) and 29 children 

required an intervention, such as returning the child to diapers or using suppositories. Stool 

toileting refusal was associated with presence of a younger sibling and the parents’ inability to 

set limits for the child. The study was conducted in a private pediatric practice of middle and 

upper class families. In a second study, Brazelton describes 1170 children who were toilet 

trained during ten years of his pediatric practice.8

 All children were trained using a child-oriented 

approach and training occurred in a pressure-free environment and only begun once the child has 

expressed interest (at approximately 18 months of age). The clinical population consisted of 

primarily upper-middle class families. For the majority of children, bowel and bladder training 

occurred simultaneously (930/1170; 79.5 percent). Daytime continence was achieved at a mean 

age of 28.5 months and nighttime continence by 33.3 months. While males and females 

completed daytime training at the same age, girls achieved nighttime continence approximately 

2.46 months sooner than boys. Sixteen children were not trained by five years of age and 

suffered from at least one of the following: 12 had enuresis, 4 soiled in stressful situations, and 8 

suffered from chronic constipation. Finally, Kaffman examined children living in one of twelve 

kibbutzes in Israel.50 Toilet training is conducted by at least six people and is led by the the head 

metapelet (caregiver). The toilet training program is child-oriented and is tailored to the child’s 

temperament, emotions, and neurophysiological development. Enuresis was defined as a lack of 

complete bladder control by the age of three and half years and the prevalence was 13.9 percent 

(192/1376). 

Two studies assessed the Azrin and Foxx method in healthy children. Foxx et al. identified 

34 children who previously attempted toilet training. The children were assessed with a 

screening test to ensure their ability to follow the toilet training program.9

 Two trainers applied 

the Azrin and Foxx method and the children were toilet trained with a mean time of 3.9 hours. 

Older children (aged 26 to 36 months) completed unprompted toileting within 2.3 hours, whereas 

the younger children required approximately 5 hours. After the Azrin and Foxx method, bladder 

and bowel accidents were reduced by 97 percent and this success was maintained at four months 

follow-up. With the exception of one parent, the parents were pleased with their child’s progress; 

however, the parent’s displeasure was not related to the toilet training method. A second study 

examined 49 children toilet trained according to Azrin and Foxx’s Toilet Training in Less than a 

Day program. Parents went to three weekly classes where they were taught the principle of the 
37

Azrin and Foxx method. Ten children failed to achieve continence within the intensive training 

session; nine of the children were less than 25 months of age. Reasons for failure include the 

child’s severe emotional reaction (n=6) and parents quitting the program (n=4). The average 

toilet training time was 4.5 hours. At 8-week follow-up, bladder and bowel control continued to 

improve, but many children were lost to follow-up.

Mentally handicapped children. A total of ten studies examined toilet training methods among 

mentally handicapped children. Four studies assessed variations of the Azrin and Foxx method 

and six utilized operant conditioning programs. 

Five studies examined variants of operant conditioning programs. Van Wagenen used 

forward-moving series toilet training to toilet train nine mentally handicapped children.65 The 

children wore an alarm that sounded at the time of urination. The trainer then said “no,” led the 

child to the toilet, and placed the child on the toilet where the child continued to urinate. Once 

this sequence was established, the alarm was replaced with cotton underwear and the children 

were taught to dress and undress. All of the children were successfully trained with this method 

and toileting skills were maintained in different toileting facilities. In the second study, Ando 

utilized operant conditioning techniques to toilet train five institutionalized autistic boys.33

Positive reinforcement for correct toileting included candy, praise, and affection, while physical 

and verbal punishment was used to negatively reinforce improper toileting behavior. The 

children were toileted every two hours or when they appeared to have to urinate. Three of the 

children improved self-initiating toileting (approximate improvement ranged from 30-60 

percent). One child had minimal improvement; self-initiating toileting increased from 0 to 20 

percent after twelve months of training. The fifth child failed to increase self-initiating toileting 

and the child did not respond to any of the positive or negative reinforcers. In the third study 

Giles et al. attempted to toilet train five severely and profoundly mentally retarded children who 

rarely displayed self-initiated toileting.11 Bladder training was only initiated after some bowel 

continence was achieved. Correct toileting behavior was positively reinforced. If positive 

reinforcement did not produce behavior modification, aversive consequences in the form of 

physical restraints were used to correct inappropriate toileting behavior. The length of the 

training program was eight weeks. All five children were successfully toilet trained. In the fourth 

study, Spencer attempted to establish bowel control in nine severely and 29 profoundly retarded 

boys.66 The operant conditioning program consisted of positive reinforcement for defecating in 

the toilet and sitting on the toilet (providing the boys were incontinent at least half of the time). 

The program was 6 weeks in length. Achieving bowel control was not significantly correlated to 

mental age, chronological age, leg coordination, sociability, negativism, emotionality, bowel 

movement frequency, brain damage or, time in institution. Spontaneous toileting increased by 9 

percent and accidents decreased by 17 percent. Improvement was more profound in children with 

a higher degree of incontinence. Using an operant conditioning program, Colwell attempted to 

improve toileting, dressing, and eating behaviors among 47 profoundly and severely mentally 

retarded children.67 The objective was to bring these behaviors under verbal control. Initially, 

tangible items were used to positively reinforce proper behavior and were then replaced with 

social praise. A 23-item toileting scale was used to measure changes in behavior. Follow-up 

ranged from 3 to 12 months. Thirty-three of the 47 children increased their toileting skills, 3 

children decreased toileting skills and the remaining 8 children experienced no change. The 

mean toileting score improved from 6.0 out of 18.0 at baseline (goes to bathroom area when 
38

asked, requires assistance with clothing, and has accidents) to 10.1 after the intervention (toilets 

on command, manages own clothing, and has few or no accidents). 

Four studies evaluated variations of the Azrin and Foxx program. Didden attempted to 

achieve prompted bowel and bladder control with six children diagnosed with Angelman 

syndrome.68 The daily 6-hour training sessions included walking to the bathroom, drinking every 

30 minutes, scheduled toileting in 30-minute intervals, remaining on toilet until elimination or 20 

minutes expires, positive reinforcement for successes, and self-dressing. If the child had an 

accident, the child was reprimanded, changed clothing, cleaned the soiled area, was denied toys, 

and had a one-hour timeout. Children were followed up at 2.5 years. At baseline, the average 

frequency of correct daily toileting was 0.8 (SD 0.95). This increased to 3.5 (SD 1.23) at posttreatment and similar results were observed at follow-up (3.1; SD 0.57). The mean time spent 

toilet training was 108.2 hrs (30.6). In the second study, Lancioni used the Azrin and Foxx 

method to toilet train nine profoundly deaf and blind children who had never shown any signs of 

self-initiated toileting.69 The training program consisted of increased liquid and decreased food, 

positive reinforcement for proper toileting behavior and remaining dry, punishment for 

accidents, increasing distance from the toilet, and removing environmental stimulus. Training 

was conducted in three phases and followed by a maintenance phase. At day 44 of follow-up, 

eight of the nine children exhibited self-initiated toilet training. In the third study, Smith 

retrospectively examined 13 mentally retarded children who were toilet trained by the Azrin and 

Foxx method.70 The children wore a urinary training device, fluid intake was increased, and 

operant conditioning techniques were used to elicit the desired toileting behavior. At baseline, 

the children had a 50 percent frequency of wetting accidents, which was reduced to 

approximately 10 percent by week 5 to 6. All three of the higher social-aged children and three 

of the five lower social-aged children maintained a near-zero accident rate at follow-up (6 to 18 

months). The remaining children experienced a slight increase in accidents. In the final study, a 

toilet training method similar to that of Azrin and Foxx was used to toilet train nine mentally 

handicapped children.71 The Azrin and Foxx method was augmented with the Big Kids book, 

which was read to the children at least once a day. There was no punishment or reinforcement of 

accidents. Follow-up measurements were taken at 2, 4, and 6 weeks. The authors found an 

increased number of success and a decreased frequency in the number of accidents. When 

compliance to each component of the toilet training program was measured, there was poor 

compliance to the Big Kids book and was deemed an unnecessary component to toilet training. 

In the final study, the population consisting of three healthy children and five mentally 

handicapped children.72 The children were subjected to a two-step operant conditioning program 

aimed at establishing all components of toileting behavior. During the first step, the children 

responded to physical, verbal, and auditory stimuli. Prompts were then elicited by the auditory 

stimulus alone. Seven of the eight children were successfully toilet trained with this method. 

Physically handicapped children. Five studies examined toilet training among children with 

various physical handicaps. All toilet training methods were classified as “other” and, with the 

exception of two papers,73 74 the toilet training programs were different. 

Van Kuyk conducted two studies that retrospectively assessed a multidisciplinary toilet 

training program among children diagnosed with anal atresia73 and Hirschsprung’s disease.74 The 

toilet training program aimed to teach adequate defecation behavior by reducing fear and anxiety 

concerning defecation and stool withholding, learning how to use the lower body to defecate, 

improving straining techniques, and defecating on a regular schedule. The program was 
39

conducted by a variety of health care professionals, including a child psychologist, pediatric 

physiotherapist, and pediatric surgeon. Among the 43 children with anal atresia, there was a 

significant improvement in the three-point continence score after treatment compared to baseline 

(Templeton score at baseline: 2.2 ± 0.45; post treatment: 1.6 ± 0.59). The Templeton score 

measures awareness of impending defecation, occurance of accidental defication, need for 

additional underwear or diaper liners, presence of diaper rash, social problems, and restriction of 

phycial activity. There were also significantly fewer children suffering from constipation (18 

versus 8). Among the 16 boys diagnosed with Hirschsprung’s disease, there was significant 

improvement in Templeton score after completing the toilet training treatment program. After 

treatment, the Templeton score decreased to 1.1 (SD 0.34) from 2.7 (SD 0.48). The number of 

constipated children was reduced from 12 to 4. The treatment was effective, regardless of the age 

of the child or the specific physical handicap. 

Three studies developed toilet training programs for establishing bowel control in children 

with spina bifida.51 75 76 In the study by King, the toilet training program aimed to establish 

neurogenic bowel habituation.75 It included training provided by a psychiatrist and establishing a 

set time for bowel elimination. Specifically, the bowel was cleaned and stool softeners, glycerin 

suppositories, bisacodyl suppositories, digital stimulation, and oral medication were incorporated 

to result in a timed defecation. The age range of the study population was 18 months to 29 years 

and results were stratified by age (≤6 years versus > 6 years of age). Among children less than or 

equal to 6 years of age, continence improved from 0 percent (0/17) to 65 percent (11/17) and 

further improved to 88 percent (8/9) among children who completed to the toilet training 

program. In the second study, Forsythe created a similar program for 47 children.76 The children 

worked through the following steps sequentially until an intervention was successful: regular 

toileting after supper, daily enemas, enemas plus suppository or microenema before evening 

meals, and enemas and daily use of laxatives. At each stage, the prior intervention(s) were also 

used. Regular toileting resulted in bowel control in 8 of the 47 children (17 percent). Seven of 

the 39 children (18 percent) achieved bowel control with a combination of regular toileting and 

enemas; 2 other children experienced initial success but relapsed after 6 to 8 months. Of the 25 

children treated with daily suppositories or micro-enemas, enemas, and regular toileting, only 5 

children attained bowel control (20 percent). Glycerin suppositories were ineffective; three 

treatment successes occurred in the bisacodyl group and two in the microenema group. Twentyseven children received a combination treatment of laxatives, enemas, and regular toileting. 

Among the 16 children using bisacodyl tablets, 12 were free from stooling accidents and were 

followed up from 9 to 24 months. All 15 children who received a laxitive syrup experienced 

bowel control and were followed up for at least 6 months. In the third study, a bowel and bladder 

toileting program was evaluated in 525 children with spina bifida and aged 1 to 18 years.51 The 

bowel training program consisted of five components: (1) untimed collection of a diaper or insert 

and cleaning by a primary care giver, (2) infrequent enemas, (3) small, rapid, low-level enemas, 

(4) suppositories, and (5) timed evacuation with or without digital stimulation. The control 

program was comprised of (1) diaper or pant insert, (2) penile collectors, and (3) urinary 

diversions with either timed bladder emptying with or with out medication or clean intermittent 

catheterization with or without medication. Dependent socially acceptable bowel control among 

children less than 3 years of age was best achieved with diaper care (15/41) and suppositories 

(14/41). Thirty-nine of the 41 children were trained. Among children over the age of 4 years, 

dependent socially acceptable bowel control was best achieved by suppository use (24/184) and 

expansion enema (12/184). The timed method was most successful for achieving independent 
40

socially acceptable bowel control (55/184), followed by suppository use (24/184). Regardless of 

age, 44 children failed to achieve socially acceptable bowel control. Among children less than 6 

years of age, socially acceptable dependent training was most frequency achieved by a 

diaper/pants insert (32/57). Only one child achieved independent socially acceptable bladder 

control and this was achieved by clean intermittent catheterization. Socially acceptable 

independent and dependent bladder control was achieved by ileal diversion (23/158 and 27/158, 

respectively). In total, 62 children did not achieve socially acceptable bladder control.
41 

Chapter 4. Discussion 

In many cultures, including North America, parents regard a child achieving independent 

toileting skills as a significant accomplishment. It is one of the first steps in becoming selfsufficient; caregivers no longer need to spend time or energy on diaper changes and there are 

financial savings in diaper costs. As such, successful toilet training is an adaptive skill that 

caregivers expect their healthy child will achieve. However, the toilet training process can cause 

some anxiety for caregivers, particularly among parents with children who have significant 

physical, mental, or behavior problems. Achieving independent toileting requires that a child 

have a combination of skills in language, motor, sensory, neurological, and social domains. For 

the child with a significant impairment in one or more of these, successful toileting can be 

problematic. 

This review summarizes the scientific evidence relating to the effectiveness of defined 

methods used to toilet train children to achieve bowel and bladder control. In addition to overall 

effectiveness, the review looked at evidence to support or refute proposed factors that might 

modify the effectiveness of toilet training (e.g. age, sex, race/ethnicity, culture, age at initiation), 

and to assess if some toilet training methods pose a risk for developing adverse outcomes such as 

dysfunctional voiding, enuresis, or encopresis. This review sought to determine the optimal toilet 

training methods for healthy children and those with mental, physical or behavioral problems. 

An extensive search for trials was conducted in databases from education, psychology, social 

sciences, and health sciences. We searched for meeting abstracts, theses, and dissertations; we 

searched for position papers from professional pediatric societies and conference proceedings. 

Only eight RCTs were identified; all compared different versions of the same method. The 

remaining 26 included studies were retrospective and prospective cohort studies; only 3 had a 

comparison group and all were children receiving usual care. For these reasons, we were not able 

to conduct a meta-analysis and the results are presented qualitatively. Notwithstanding, some 

valuable general information does arise from this review in the form of a descriptive analysis. 

Three primary toilet training methods were identified and examined for training healthy and 

mentally handicapped children: Azrin and Foxx, operant conditioning, and a child-oriented 

approach. The interventions used to train some children, particularly those with physical 

handicaps, were specifically designed to work with their particular problems and abilities; we 

categorized these as “other” methods. 

Toilet Training Healthy Children 

Toilet training for healthy children is not a subject that invokes passion among researchers; 

however, parents and pediatricians struggle with this seemingly minor problem on a daily basis. 

Pediatricians faced with the task of providing evidence-based advice have difficulty finding the 

literature to support the various approaches.77

Most parents want to know the quickest, easiest approach to toilet training that does not 

result in adverse outcomes. Parents are inundated with media and lay information on various 

methods from the child oriented approach to the extreme and time intensive method of 

elimination communication where an infant may be diaperless from birth.78 Despite this 

method’s growing popularity in North America, we did not identify any studies that examined 

the elimination communication toilet training method. A method similar to this idea was used 

among the Digo people of East Africa; however, the article did not report any quantitative results 
42

and thus failed to meet our inclusion criteria. The author did state that toilet training success was 

achieved by infants 4 to 6 months old.5

 

In this review, we identified three randomized trials looking at toilet training methods in 

healthy children.44 54 58 Unfortunately, there were no head-to-head comparisons between the 

child-oriented approach8

 and the Azrin and Foxx method9 and this prevented us from drawing 

definitive conclusions regarding one method’s superiority over the other. The rather regimented 

Azrin and Foxx approach appeared to result in rapid success, Matson reported 50 percent success 

with 10 toddlers aged 20 to 26 months after 5 four-hour sessions. At the 10 week follow-up, one 

child had regressed to diapers due to parental problems.58 Candelora found Azrin and Foxx to be 

superior at reducing accidents, increasing successes, and reducing the number of wet mornings 

than the Spock method.54 In the one large study examining the child-oriented approach, the 

positive approach to bowel habits and avoidance of negative terminology in reference to 

defecation improved the time to fecal continence by 3 months; however, this may not be 

clinically significant.44 These children were completely toilet trained at a much later age (3.5 ± 

0.5 years) in comparison to those by the Azrin and Foxx method. 

While single-cohort studies are a lower level of evidence, they do provide insight into 

outcomes, particularly when there is limited higher-level evidence available. The two cohort 

studies examining the effectiveness of the Azrin and Foxx method concurred with the Matson 

trial.9 79 Children seem to attain continence quickly, with a relatively high success rate and at a 

relatively early age. Following one day of training, Butler reported 74 percent success in 34 

toddlers under 25 months and 93 percent success in 15 older toddlers; Foxx reported 100 percent 

success in 34 toddlers ranging from 20-36 months. Success at follow-up was 96 percent and 97 

percent respectively. One of the larger studies was a prospective cohort of children who trained 

using the child-oriented approach.41 With this approach, 61 percent (292/482) were continent by 

the age of 3 years and 98 percent were continent by 4 years of age. The study does not state how 

long it took to achieve continence. 

 Unfortunately there is insufficient evidence to provide conclusive answers regarding the 

optimal toilet training method. Overall, we found that in the small studies evaluating the Azrin 

and Foxx method, success is relatively high and achieved soon after training. Follow-up at 1to 4 

months indicated success was maintained. Successes were also seen in the child-oriented 

approach, but they generally did not occur as quickly as those displayed by the Azrin and Foxx 

method. Brazelton’s retrospective study reported that 94 percent of parents (1105/1170) started 

toilet training between 12 to 24 months and that 26 percent (304/1170) had completed day time 

training by 24 months.8

 In general, both toilet training programs seem to have the ability to teach 

toilet training in healthy children. It appears from the literature that parents who want quick 

results should consider the Azrin and Foxx method of toilet training but must be prepared for a 

regimented approach and should use positive reinforcement. For parents who are not prepared to 

put as much focus into attaining continence, the child-oriented approach can be successful but 

may take somewhat longer. Until we have additional studies that compare the toilet training 

methods, it appears safe to tailor the approaches in healthy children to individual families. This 

recommendation is in keeping with Brazelton’s review article.3
43

Toilet Training Mentally Handicapped Children 

Many caregivers of mentally handicapped children want to know if the child will ever attain 

independent, successful toileting, and if so, what toilet training methods exist to facilitate this 

process. Our search strategy identified a limited number of comparative and single-arm studies. 

Many of them were from the 1960s and 1970s and the definition of mental retardation has 

undergone several revisions, mainly that the lower IQ limit decreased from 85 to 70. As such, 

some of the children who were classified as mentally retarded in these older studies may not 

meet the current definition. 

One of the key questions was to identify toilet training strategies and/or outcomes of children 

with behavior problems. Unfortunately, no studies involving this population were identified. 

Some children with mental retardation can have behavior co-morbidities; however, in studies of 

mixed populations, results were not specified by the diagnoses. A small (n=5) prospective cohort 

of children with autism and mental retardation had some success with an operant conditioning 

method and toilet training was more successful in children with receptive language skills.33

Another small (n=9) study in autistic mentally retarded children found that improved access to a 

potty could assist in toilet training.64 Children who were mentally retarded secondary to 

Angelman syndrome had partial success in toileting using a modified Azrin and Foxx method.68

Although this study did not specify the behavior problem(s), Angelman syndrome is often 

associated with hyperactivity and characteristic bouts of laughter. Given that many children who 

are otherwise healthy but have significant behavior problems, including but not exclusive to 

attention-deficit disorder and oppositional defiant disorder, future studies should be designed to 

examine toileting strategies and outcomes in these children. 

Based on single-arm studies, mentally handicapped children had some degree of success 

regardless of the toilet-training method used. From the comparative studies, the Azrin and Foxx 

method, operant conditioning, and relaxation techniques were all superior to not using a toilet 

training method. Unfortunately, none of the studies did a head-to-head comparison between the 

different toilet training methods. Furthermore, the child-oriented method was not used in any of 

the studies on mentally handicapped children. 

Even though studies are few and have small sample size, the evidence suggests that some 

mentally retarded children can attain at least partial success with toilet training. At present all of 

the strategies seem equivocal, thus caregivers and health care providers can try any of the 

methods. Success may be optimized among those with receptive language skills and easy access 

to a toilet. 

Given there is a broad spectrum of function in mentally retarded children, often confounded 

by physical and behavior problems, caregivers and health care providers may need to be flexible 

when developing toilet training strategies. 

Toilet Training Physically Handicapped Children 

 Children with physical handicaps face difficulties with bowel and bladder control related to 

the physiology and psychology of their conditions. In many conditions, such as Hirschsprung’s 

disease and other congenital anal anomalies (e.g. anal atresia and spina bifida), children may not 

have the abilities to develop control with standard toilet training methods. We included this 

patient population into this systematic review in an effort to develop insight into toilet training 

this particular group of children. 
44

 We did not find any studies that evaluated the child-oriented approach or the Azrin and Foxx 

method in children with physical disabilities. In the one prospective controlled trial 27 children 

with Hirschsprung’s disease were successful with a multidisciplinary (Evidence Table D-6) 

approach to toilet training.52 While this was only one small study with only 9 months of followup, it is clear that for children with complicated medical conditions, this approach is favored. Not 

only are results generally better, but also families tend to be more satisfied with their care. 

 The multidisciplinary approach to bowel control was also assessed in two retrospective 

cohort studies of children with anal atresia and Hirschsprung’s.73 74 The results confirmed those 

of the trial and the belief among most specialists was that children with complex conditions 

required the expertise of many specialists in a interdisciplinary fashion. Children with spina 

bifida present with different elimination problems due to varying degrees of neurologic 

impairment at different spinal cord levels. With regard to the bowel, they can suffer from 

constipation and/or fecal incontinence. Urinary symptoms can include failure to empty as well as 

incontinence. Standard methods for toilet training rarely work in this patient population. The 

primary means to control these problems are timed evacuation as described in the three cohort 

studies.51 75 76 With timed elimination via clean intermittent catheterization, stool softeners, 

suppositories and enemas, children have the ability to become continent. The long-term success 

varied and few children were able to remain continent without some sort of medical intervention. 

Families of children with complex medical conditions should not expect their children to toilet 

train as per healthy children; however, there are many options to gain continence. Parents should 

be made aware of the difficulties and the potential solutions in order to avoid unreasonable 

expectations. Identifying support groups for families is often helpful in order to expose them to 

the unique solutions used by other children with complex medical conditions. 

Modifying Factors that May Affect Toilet Training 

 While there were no studies that looked specifically at modifying factors, some common 

themes were found among the studies. Candelora found that certain parental variables improved 

outcomes, such as having older and more tolerant mothers, and higher socioeconomic status.54

Butler and Taubman’s studies revealed quicker training in girls than boys.41 79 On the other hand, 

Brazelton did not report a difference in attaining daytime continence between sexes but did 

observe a quicker attainment of nighttime continence in girls.8 44 Taubman et al. also revealed an 

association between the presence of younger siblings and a higher incidence of stool toileting 

refusal.44 While race and culture were not evaluated in these studies, they may play a role in 

expectations, choices of interventions, and accepted norms. 

Adverse Outcomes Associated with Toilet Training 

 Only four studies specifically addressed the topic of adverse outcomes: two addressed 

bladder problems retrospectively,50 59 one examined bowel problems prospectively,41 and one 

reported unspecified residual problems also prospectively.8

 Regarding long term bladder control, 

one cohort59 determined that school age children with lower urinary tract symptoms (21 percent 

of the sample) were trained at a later age (>18 months) and that their parents had used more 

aggressive methods to provoke voiding (e.g. ran water, asked to push); however, no specific 

training methods were compared and data were collected via a questionnaire when the children 

were approximately ten years of age. The second study reported the frequency of enuresis in 

those that had been trained by multiple caregivers on a kibbutz; training began between 15 and 
45

24 months.50 At six to seven years of age, they had a higher incidence of enuresis than nonkibbutz raised children, but a lower incidence after age ten. On the topic of prolonged bowel 

incontinence the one prospective RCT reported an incidence of approximately 22 percent for 

stool toileting refusal.41 These problems were associated with the presence of younger siblings, 

parental difficulty in setting limits, and training at a later age; however, “later” was defined as 

children >42 months as compared to 18 months, which was used by Bakker59. These children 

were trained in a child-oriented fashion. In contrast, Brazelton reported a 1.4 percent incidence 

of residual problems at >5 years of age following a child-oriented training approach.8

 None of 

the operant conditioning or Azrin and Foxx studies reported these outcomes. The only other 

adverse effects mentioned in these studies were temper tantrums and child and parental refusals 

and frustration with the training method itself. 

Limitations 

There are a variety of limitations associated with this review, including bias, variation in 

study definitions, weak study design, variability in the toilet training programs, and lack of 

statistical analysis. Also, the majority of the studies were conducted between the1960s to the 

1980s. 

As with all systematic reviews, there is a possibility of publication and selection bias. To 

reduce publication bias, an experienced medical librarian conducted a comprehensive search of 

the published literature for potentially relevant studies using a systematic strategy. This was 

augmented with hand searching of reference lists and conference proceedings and tracking 

forward sentinel articles. Overall, toilet training was a well-indexed subject and we are confident 

that the search located all the major literature on this topic. Despite these efforts, we recognize 

that unpublished negative studies may have been missed. Although the search was conducted 

without language restrictions, in the end the review was restricted to English articles due to 

difficulties in obtaining complete, accurate translations in more than ten non-English languages. 

It is likely that approximately three additional foreign studies might have been included. 

Selection bias was controlled by having two reviewers apply a priori inclusion criteria 

independently then resolve all discrepancies with a third party who had clinical expertise. We 

feel confident that the studies excluded were done so for consistent and appropriate reasons. 

 Prior to determining effectiveness, it is necessary to have a clear, specific, and measurable 

definition of the end result. In the case of toilet training, there is no all-encompassing definition 

and each of the included studies varied in their definition of success. The populations studied in 

this review displayed great heterogeneity; healthy children and those with special needs 

involving either mental or physical handicaps are included. As a result, the definition of success 

had to be modified. For some it meant total and lasting self-directed independent toileting, 

including recognizing elimination urges, going to a toilet, handling clothing, assuming proper 

positioning, attending to sanitation, and returning to activities without notifying anyone; other 

definitions were less inclusive regarding which aspects of the process must be complete and for 

how long before success was accorded. In institutionalized populations, improvement in 

frequency of toileting successes and reduced accidents resulting in less laundry and less staff 

time spent toileting and cleaning was reward enough for implementing a program although some 

participants did achieve independent toilet skills. For those with neurophysiological handicaps, 

attaining social acceptability, independently or not, and sometimes not until late teen years was 

the goal. Some of the populations had been subjected to previous unsuccessful attempts to toilet 

train; others were attempting training for the first time. These variations in populations, 
46

definitions of success and failure, and reported outcomes proved too disparate to permit pooling 

of results. 

A second limitation of this review is the weakness of the study design that the majority of the 

studies used. There were only eight RCTs. Among the other studies comparing two or more 

toilet training programs, the majority of the interventions were non-randomized and the rationale 

for the intervention decision was largely unknown. The quality of included studies varied and 

was generally low. All RCTs received a low methodological score (1 or 2 of a possible 5 points); 

the only reported details were that group assignment was random (with the exception of one 

study) and withdrawals and dropouts were accounted for. How the randomization code was 

derived, concealed, and applied is unknown and the nature of intervention does not lend itself to 

double blinding. The cohort studies scored a mean of 16.9 ± 3.1 of a possible 29 (range 11-22). 

However, it should be noted that 70 percent of the studies were published before the CONSORT 

guidelines were introduced to improve reporting requirements particularly for RCTs; therefore, it 

is unclear if the poor reported methodological quality is a reflection of reporting omissions or 

true methodological quality.80 Some of the prospective cohort studies that were dependent on 

observer evaluation made an effort to have two observers and calculated agreement to improve 

accuracy. 

A third limitation is imposed by the variability in the programs themselves. The most studied 

intervention was the Azrin and Foxx method and this was assessed in nine studies; however, 

there was significant variation in which aspects were incorporated, who did the training, and the 

extent of training the trainers received prior to implementing the program. Four were conducted 

on healthy children (2 RCTs, 2 prospective cohorts). Three of these studies used the Toilet 

Training in Less Than a Day Program (TTLD); two involved parents (some pre-trained, some 

not, some supervised, some not) training the children at home; the other used qualified trainers 

who conducted the training in a separate facility. The toilet training success rate was lower when 

the child was trained by parents versus the qualified trainer: 50 and 78 percent compared to 100 

percent. Parents reported a high incidence of negative emotional reactions to the procedure while 

the trainers reported that most children responded as if it were a very pleasant experience. 

Candelora reported the TTLD program was superior to Dr. Spock’s recommendations.54 The 

Azrin and Foxx method was used in five studies involving mentally handicapped children (one 

RCT, three prospective and one retrospective cohort); two used potty and pant alerts (success 

rates 60 and 89 percent), three did not (success rates 60 percent, 100 percent and significant 

improvement in successes). All studies modified the method to suit the particular population or 

staff availability and costs. Because of the heterogeneity in design, populations, implementation, 

the definitions of success, and outcomes reported, data results could not be pooled. In general, 

though, it can be said that the Azrin and Foxx method produced many more successes than 

failures with both healthy and mentally handicapped children. 

The toilet training programs and populations were diverse and were assessed using a variety 

of study designs. A child-oriented toilet training method was used in four studies (1 RCT, 3 

single cohort: 1 prospective, 2 retrospective) all involving healthy developing children. Parents 

were the sole trainers in three of the studies and were part of a multiple caregiver approach on a 

kibbutz in the other. Only one reported a training success rate (98 percent by age 4 yr). The other 

studies were investigating on-going bowel and bladder incontinence but training success can be 

assumed to be 80 percent without problems (generally by 3.5 yrs of age).8

An operant conditioning method was investigated in twelve studies (2 RCTs, 9 cohort: 5 

single, 5 with a control group). All were prospective, eleven involved mentally handicapped 

populations, (one study used three healthy children as comparison group) and one was conducted 

among children with a physical handicap. Two investigators looked at the use of auditory signals 
47

to train children. Three of the healthy children were successful and four of nine mentally 

handicapped children achieved criterion success levels. Two programs involving ten children 

administered negative consequences for incontinent episodes in addition to positive 

reinforcement for appropriate actions. Five subjects achieved consistent self-initiated control, 

four improved between 18 to 60 percent and one did not respond. The remaining eight studies 

reported only positive reinforcement procedures were employed. Though results are reported in 

various ways and cannot be combined, they all indicated that operant conditioning interventions 

yielded improvements over control groups—toileting scores increased, wetting/soiling accidents 

decreased, laundry requirements decreased, and Templeton/Wingspread/constipation scores 

improved. 

A fourth limitation lies in the fact that several of the studies did not perform a statistical 

analysis of their own data and only reported results in a descriptive fashion. A descriptive 

analysis has several limitations and provides the clinical reader with less information to guide 

future actions. This review provides a table describing the population, each intervention and a 

range of outcomes depicting success/partial success/and failure rates along with the authors’ 

conclusions. A handful of studies address negative consequences of a program, thus leaving this 

topic largely unexplored. It allows the reader to draw their own conclusions but fails to answer 

specific clinical questions. Without a pooled statistical analysis it is difficult to draw conclusions 

that can be generalized to similar populations in the clinical setting. While we have made limited 

progress in determining whether one toilet training program is more effective than another, we 

do know that all programs elicited a measure of success and that the majority of children 

achieved a higher level of, if not complete, continence. 

Future Research Opportunities 

To date, toilet training research is hampered by heterogeneity and methodological flaws. The 

first step to improving the state of toilet training research is to standardize definitions related to 

toilet training, such as “toilet trained,” “successes,” and “failures.” Second, studies with larger 

sample sizes should be undertaken. Because almost all children are toilet trained, there is 

potential for large-scale research. 

Given the findings of this systematic review, the following future research priorities are 

recommended: 

• Definitions of toilet training should be standardized and where appropriate, cultural 

definitions should be developed. The same principles of standardization should be 

applied to outcome measures. 

• While toilet training interventions do not lend themselves to double-blind trials, the 

methodological quality of future trials could be enhanced by having blinded outcome 

assessors and concealing allocation. 

• The child-oriented approach requires further evaluation and the effectiveness of the 

elimination communication method needs to be determined. 

• Few studies examined factors that may affect or modify toilet training. Additional 

research is required to examine the effects of modifiers such as maternal age, parenting 

experience, child temperament, and match or miss-match of parent-child relationship on 

toilet training success. 

• Studies that directly compare two toilet training methods, such as Azrin and Foxx to 

child-oriented approach, within the same population should be undertaken to determine 

the most effective toilet training program. 
48

• In an attempt to reduce bias, future studies should be randomized controlled trials or large 

prospective cohort studies. 

• Among the studies examining toilet training among mentally handicapped children, very 

few described the exact mental handicap. The applicability of the study results would be 

enhanced if there were increased details concerning the nature of the handicaps. 

• Few studies examined adverse outcomes associated with the particular toilet training 

method. There is a need for long-term follow-up that measures the occurrence of adverse 

events, such as enuresis, encopresis, stool withholding, stool toileting refusal, and other 

psychological consequences. 

• It has been hypothesized that toilet training is more challenging among children with 

behavioral disorders, such as autism and attention deficit disorder; however, there is a 

paucity of evidence examining toilet training in this specific group of children. Toilet 

training programs should be assessed in children suffering from behavioral disorders. 

Conclusions 

Toilet training is an important milestone in pediatric development. There are several different 

toilet training methods; however, the individual programs have not been well researched. Few 

trials have examined the various toilet training programs and the existing trials tend to compare 

variations of the same program and not one toilet training method to another. A more popular 

study design among the toilet training literature is the single cohort: generally, a small group of 

children were toilet trained using the same method and continence was subsequently assessed. 

The individual studies were heterogeneous, as the children, toilet training interventions, 

measured outcomes, and definitions of ‘toilet trained’ were variable. 

After a comprehensive search of electronic databases, conference proceedings, and reference 

lists of included articles, we identified 8 controlled trials and 26 observational studies that 

examined toilet training methods in healthy and handicapped children. Based on the evidence, 

the following conclusions can be made: 

• The studies are heterogeneous and the methodological quality of the included studies is 

poor. For this reason, the results and conclusions should be interpreted cautiously. 

• Both the Azrin and Foxx and child-oriented methods successfully toilet trained healthy 

children. However, although the effectiveness of variants of the child-oriented approach 

and Azrin-Foxx has been studied, the child-oriented approach has not been directly 

compared to the Azrin-Foxx method. 

• No study evaluated the early communication method. 

• Toilet training methods in children with behavioral or developmental handicaps were not 

well studied. 

• There is some evidence that, among healthy children, the Azrin and Foxx method may 

train children sooner than the child-oriented approach but there was limited research to 

determine if the achieved continence was maintained. In addition, the two methods have 

not been directly compared to determine the time to achieving continence. 

• Azrin and Foxx and operant conditioning toilet training programs were used to partially 

or completely toilet train mentally handicapped children. 

• For children suffering from Hirschsprung’s disease and anal atresia, a multidisciplinary 

approach to toilet training proved to be successful for achieving bowel continence. 
49

• Timed evacuation also was successful for obtaining bowel control among children with 

physical handicaps. 

• Few analyses have been conducted to identify effect modifiers; they were only assessed 

in studies that attempted to toilet train healthy children. 

• There was mixed evidence regarding sex of the child and toilet training; two of the three 

studies concluded that girls trained earlier than boys, while the third study found that girls 

achieved nighttime continence before boys. 

• Adverse outcomes were seldom assessed and only in the child-oriented approach. Later 

age of training (>42 months), younger siblings, and parents not being able to set limits for 

their child tended to be associated with adverse events. 

• Later age of toilet training and aggressive toilet training methods were associated with 

subsequent urinary tract symptoms. 
50
51

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55

Figure 3. Reported success of toilet training among healthy children The size of the shape is proportional to sample size. Square=RCT, circle=prospective cohort, triangle=retrospective cohort. 

Azrin-Foxx

0

102030405060708090

100

% of successes

Child-oriented

0

102030405060708090

100

% of successes

Operant Conditioning

0

102030405060708090

100

% of successes
56

Figure 4. Reported success of toilet training among mentally handicapped children The size of the shape is proportional to sample size. Square=RCT, circle=prospective cohort, triangle=retrospective cohort.

Azrin-Foxx

0

102030405060708090

100

% of successes

Operant Conditioning

0

102030405060708090

100

% of successes

Other

0

102030405060708090

100

% of successes
57

Figure 5. Reported success of toilet training among physically handicapped children The size of the shape is proportional to sample size. Square=RCT, circle=prospective cohort, triangle=retrospective cohort. 

Operant Conditioning

0

102030405060708090

100

% of successes

Other

0

102030405060708090

100

% of successes
58
A-1 

Appendix A: Exact Search Strings 

 Table A-1. MEDLINE®

 Table A-2. OLDMEDLINE®

 Table A-3. MEDLINE® In-Process & Other Non-Indexed Citations 

 Table A-4. EBM Reviews - Cochrane Central Register of Controlled Trials 

 Table A-5. EMBASE 

 Table A-6. CINAHL® (Cumulative Index to Nursing & Allied Health Literature) 

 Table A-7. PsycINFO®

 Table A-8. ERIC® (Educational Resources Information Center) 

 Table A-9. AMED (Allied and Complementary Medicine) 

Table A-10. EBM Reviews Full Text - Cochrane Database of Systematic Reviews 

(CDSR), ACP Journal Club (ACPJC), Database of Abstracts of Reviews of 

Effects (DARE) 

Table A-11. HealthSTAR/Ovid Healthstar 

Table A-12. Biological Abstracts 

Table A-13. Sociological Abstracts 

Table A-14. Web of Science®

Table A-15. Dissertation Abstracts 

Table A-16. NLM Gateway (U.S. National Library of Medicine) 

Table A-17. OCLC ProceedingsFirst 

Table A-18. OCLC PapersFirst 

Table A-19. Index to Theses 

Table A-20. National Research Register’s Projects Database 

Table A-21. American Academy of Pediatrics Web site 

Table A-22. Canadian Paediatric Society Web site 

Table A-23. Current Controlled Trials Web site 

Table A-24. ClinicalTrials.gov Web site 
A-2 

Table A-1. MEDLINE®—Ovid Version: rel10.2.0 

1966 to May Week 4 2005 

Searched June 2, 2005 

Set # and Keyword Search 

1. exp Toilet Training/ 

2. ((toilet or potty) adj3 (train$ or learn$ or condition$ or teach$ or educat$ or behavior$ or 

behaviour$)).mp. 

3. or/1-2 

Results: 753 
A-3 

Table A-2. OLDMEDLINE®—Ovid Version: rel10.2.0 

1950 to 1965 

Searched June 2, 2005 

Set # and Keyword Search 

1. ((toilet or potty) adj3 (train$ or learn$ or condition$ or teach$ or educat$ or behavior$ 

or behaviour$)).mp. 

Results: 8
A-4 

Table A-3. MEDLINE® In-Process & Other Non-Indexed Citations—Ovid Version: rel10.2.0 

Searched June 1, 2005 

Set # and Keyword Search 

1. ((toilet or potty) adj3 (train$ or learn$ or condition$ or teach$ or educat$ or behavior$ 

or behaviour$)).mp. 

Results: 7 
A-5 

Table A-4. EBM Reviews - Cochrane Central Register of Controlled Trials—Ovid Version: rel10.2.0

1950 to 2nd Quarter 2005 

Searched June 2, 2005 

Set # and Keyword Search 

1. ((toilet or potty) adj3 (train$ or learn$ or condition$ or teach$ or educat$ or behavior$ 

or behaviour$)).mp. 

Results: 40 
A-6 

Table A-5. EMBASE—Ovid Version: rel10.2.0

1988 to 2005 Week 22 

Searched June 2, 2005 

Set # and Keyword Search 

1. ((toilet or potty) adj3 (train$ or learn$ or condition$ or teach$ or educat$ or behavior$ 

or behaviour$)).mp. 

Results: 194 
A-7 

Table A-6. CINAHL® (Cumulative Index to Nursing & Allied Health Literature)—Ovid Version: rel10.2.0 

1982 to May Week 4 2005 

Searched June 2, 2005 

Set # and Keyword Search 

1. exp Toilet Training/ 

2. ((toilet or potty) adj3 (train$ or learn$ or condition$ or teach$ or educat$ or behavior$ 

or behaviour$)).mp. 

3. or/1-2 

Results: 190 
A-8 

Table A-7. PsycINFO®—Ovid Version: rel10.2.0

1872 to May Week 4 2005 

Searched June 2, 2005 

Set # and Keyword Search 

1. exp toilet training/ 

2. ((toilet or potty) adj3 (train$ or learn$ or condition$ or teach$ or educat$ or behavior$ 

or behaviour$)).mp. 

3. or/1-2 

Results: 437 
A-9 

Table A-8. ERIC® (Educational Resources Information Center)—Ovid Version: rel10.2.0

1966 to July 2004 

Searched June 2, 2005 

Set # and Keyword Search 

1. ((toilet or potty) adj3 (train$ or learn$ or condition$ or teach$ or educat$ or behavior$ 

or behaviour$)).mp. 

2. exp Toilet Training/ 

3. or/1-2 

4. limit 3 to "audiovisual or non print materials" 

5. 3 

6. limit 5 to ("guides for all non classroom use" or guides for classroom use, learner or 

guides for classroom use, teacher or guides, general) 

7. 3 

8. limit 7 to ("book or product reviews" or books or "collected works (general and 

serials)") 

9. 3 not (4 or 6 or 8) 

Results: 87 
A-10

Table A-9. AMED (Allied and Complementary Medicine)—Ovid Version: rel10.2.0 

1985 to May 2005 

Searched June 2, 2005 

Set # and Keyword Search 

1. ((toilet or potty) adj3 (train$ or learn$ or condition$ or teach$ or educat$ or behavior$ 

or behaviour$)).mp. 

Results: 13 
A-11

Table A-10. EBM Reviews Full Text - Cochrane Database of Systematic Reviews (CDSR), ACP Journal Club 

(ACPJC), Database of Abstracts of Reviews of Effects (DARE)—Ovid Version: rel10.2.0

CDSR: 2nd Quarter 2005; ACPJC: 1991 to March/April 2005; DARE: 2nd Quarter 2005 

Searched June 2, 2005 

Set # and Keyword Search 

1. ((toilet or potty) adj3 (train$ or learn$ or condition$ or teach$ or educat$ or behavior$ 

or behaviour$)).mp. 

Results: 9 
A-12

Table A-11. HealthSTAR/Ovid Healthstar—Ovid Version: rel10.2.0 

1975 to May 2005 

Searched June 2, 2005 

Set # and Keyword Search

1. ((toilet or potty) adj3 (train$ or learn$ or condition$ or teach$ or educat$ or behavior$ 

or behaviour$)).mp. 

2. limit 1 to nonmedline 

Results: 1 
A-13

Table A-12. Biological Abstracts—WebSPIRS from SilverPlatter®, Version 4.3 

1969 to April 2005 

Searched June 2, 2005 

Set # and Keyword Search

1. (TOILET-TRAINING-AGE) or (TOILET-TRAINING-EATING) or (TOILET-TRAININGONSET) or (TOILET-TRAINING-PROCEDURES) or (TOILET-TRAININGREGRESSION-SLEEP-PATTERN-CHANGE-FEEDING-HABIT-CHANGE-PEERRELATIONSH) or (TOILET-TRAINING) 

Results: 41 
A-14

Table A-13. Sociological Abstracts—CSA Illumina

1963 to May 2005 

Searched June 6, 2005 

Set # and Keyword Search 

1. Toilet train* or potty train* 

Results: 23 
A-15

Table A-14. Web of Science® (Science Citation Index Expanded and Social Sciences Citation Index)—ISI Web 

of Knowledge 

1900 to June 4, 2005 

Searched June 6, 2005 

Set # and Keyword Search

1. TS=(toilet train*) OR TS=(potty train*) 

Results: 273 

The Cited Reference Search feature in Web of Science was used to find articles that cited any of the 

following: 

 1. Bakker E, Van Gool JD, Van Sprundel M, et al. Results of a questionnaire evaluating the effects of 

different methods of toilet training on achieving bladder control. BJU International 2002;90(4):456-61. 

 2. Blum NJ, Taubman B, Nemeth N. Relationship between age at initiation of toilet training and duration of 

training: a prospective study. Pediatrics 2003;111(4):810-4. 

 3. Brazelton TB, Christophersen ER, Frauman AC et al. Instruction, timeliness, and medical influences 

affecting toilet training. Pediatrics 1999;103(6):1353-8. 

 4. Issenman RM, Filmer RB, Gorski PA. A review of bowel and bladder control development in children: 

how gastrointestinal and urologic conditions relate to problems in toilet training. Pediatrics 

1999;103(6):1346-52. 

 5. Schum TR, Kolb TM, McAuliffe TL, et al. Sequential acquisition of toilet-training skills: a descriptive 

study of gender and age differences in normal children. Pediatrics 2002;109(3):E48. 

 6. Stadtler AC, Gorski PA, Brazelton TB. Toilet training methods, clinical interventions, and 

recommendations. American Academy of Pediatrics. Pediatrics 1999;103(6):1359-68. 

 7. Taubman B, Blum NJ, Nemeth N. Children who hide while defecating before they have completed toilet 

training: a prospective study. Arch Pediatr Adolesc Med 2003;157(12):1190-2. 

8. Taubman B, Blum NJ, Nemeth N. Stool toileting refusal: a prospective intervention 

targeting parental behavior. Arch Pediatr Adolesc Med 2003;157(12):1193-6. 

Results: 32 
A-16

Table A-15. Dissertation Abstracts—ProQuest®

1861 to May 2005 

Searched June 6, 2005 

Set # and Keyword Search 

1. Toilet train* or toilet learn* or potty train* 

Results: 36 
A-17

Table A-16. NLM Gateway (U.S. National Library of Medicine) 

1950 to June 6, 2005 

Searched June 6, 2005 

Set # and Keyword Search

1. Toilet Training[MESH] OR "toilet train*" or "potty train*" 

Results: 0 
A-18

Table A-17. OCLC ProceedingsFirst—OCLC FirstSearch

1993 to June 6, 2005 

Searched June 6, 2005 

Set # and Keyword Search

1. Toilet train* or toilet learn* or potty train* 

Results: 1 
A-19

Table A-18. OCLC PapersFirst—OCLC FirstSearch

1990 to June 7, 2005 

Searched June 7, 2005 

Set # and Keyword Search 

1. Toilet train* or toilet learn* or potty train* 

Results: 6 
A-20

Table A-19. Index to Theses—Expert Information Ltd. 

1970 to May 19, 2005 

Searched June 7, 2005 

Set # and Keyword Search 

1. Toilet train* 

Results: 1 
A-21

Table A-20. National Research Register’s Projects Database—Update Software Ltd.

2000 to March 2005 

Searched June 10, 2005 

Set # and Keyword Search

1. Toilet training (Medical Subject Heading) 

Results: 3 
A-22

Table A-21. American Academy of Pediatrics Web site (http://www.aap.org/) 

Searched June 7, 2005 

Set # and Keyword Search

1. “toilet training” 

Results: 2 
A-23

Table A-22. Canadian Paediatric Society Web site (http://www.cps.ca/) 

Searched June 7, 2005 

Set # and Keyword Search

1. toilet training 

Results: 1 
A-24

Table A-23. Current Controlled Trials Web site (http://www.controlled-trials.com/) 

Searched June 8, 2005 

Set # and Keyword Search

1. toilet training 

Results: 0 
A-25

Table A-24. ClinicalTrials.gov Web site (http://clinicaltrials.gov/) 

Searched June 8, 2005 

Set # and Keyword Search

1. toilet training 

Results: 0 
B-26

Appendix B: Sample Forms 

Form B-1. Inclusion form for the effectiveness of different methods of toilet training for bowel 

and bladder control 

Form B-2. Assessment of methodology for non-randomized controlled trials for the 

effectiveness of different methods of toilet training for bowel and bladder control 

Form B-3. Assessment of methodology for controlled trials for the effectiveness of different 

methods of toilet training for bowel and bladder control 

Form B-4. Data extraction for the effectiveness of different methods of toilet training for bowel 

and bladder control 
B-27

Form B-1. Inclusion form for the effectiveness of different methods of 

toilet training for bowel and bladder control 

Reviewer: Date: Reference Number: 

TOPIC, include if either: 

[ ] Examining at least one method used to toilet train 

DESIGN, include if any of the following: 

[ ] Randomized clinical trial 

[ ] Controlled clinical trial 

[ ] Prospective cohort 

[ ] Retrospective cohort 

[ ] Case-series of at least 5 children 

[ ] Cross-sectional 

PARTICIPANTS, include if: 

Infants, toddlers, or children who do not have enuresis or encopresis and: 

[ ] Are normally developed 

[ ] Have special needs, such as physical co-mortibidities, neuro-muscular, cognitive, and/or 

behavioral disabilities 

INTERVENTION, include if there is at least one of the following toilet training methods: 

[ ] Azrin and Foxx 

[ ] Child-oriented 

[ ] Operant conditioning 

[ ] Behavioral therapy 

[ ] Infant assisted toileting 

[ ] Other: 

OUTCOMES, include if there is at least one of the following quantified, objective 

outcomes: 

[ ] Success or failure in achieving bowel control 

[ ] Success or failure in achieving bladder control 

[ ] Time required to complete toilet training 

[ ] Other: _________________________ 

[ ] Adverse events (e.g.: enuresis, encopresis, stool withholding, stool toileting refusal) 
B-28

FINAL DECISION: 

[ ] INCLUDE (meets all of the above inclusion criteria) 

[ ] EXCLUDE 

[ ] CAN’T TELL 

If disagreement between reviewers, final outcome: 

[ ] INCLUDED [ ] EXCLUDED 

Check box if study provides useful background information 
B-29

Form B-2. Assessment of methodology for non-randomized 

controlled trials for the effectiveness of different methods of toilet 

training for bowel and bladder control 

Reporting 

1. Is the hypothesis/aim/objective of the study clearly described? This question refers to a 

clear statement of the objective, i.e. to measure the effectiveness of x in population y with 

respect to z, even if x, y and z are not clearly described (see questions 2, 3 and 4). 

Yes 1 

No 0 

2. Are the main outcomes to be measured clearly described in the Introduction or 

Methods section? If the main outcomes are first mentioned in the Results section, the 

question should be answered no. In case-control studies the case definition should be 

considered the outcome. 

Yes 1 

No 0 

3. Are the characteristics of the patients included in the study clearly described in the 

Introduction or Methods section? In cohort studies and trials, inclusion and or exclusion 

criteria should be given. In case-control studies, a case definition and the source for controls 

should be given. 

Yes 1 

No 0 

4. Are the interventions of interest clearly described in the Introduction or Methods 

section? Treatments and placebo (where relevant) that are to be compared should be clearly 

described. 

Yes 1 

No 0 
B-30

5. Are the distributions of principal confounders in each group of subjects to be compared 

clearly described? A list of principal confounders is provided. 

Yes 2 

Partially 1 

No 0 

6. Are the main findings of the study clearly described? Simple outcome data (including 

denominators and numerators) should be reported for all major findings so that the reader can 

check the major analyses and conclusions. This question does not cover statistical tests, 

which are considered below. 

Yes 1 

No 0 

7. Does the study provide estimates of the random variability in the data for the main 

outcomes? In non-normally distributed data the inter-quartile range of results should be 

reported. In normally distributed data the standard error, standard deviation or confidence 

intervals should be reported. If the distribution of the data is not described, it must be 

assumed that the estimates used were appropriate and the question should be answered yes. 

Yes 1 

No 0 

8. Have all important adverse events that may be a consequence of the intervention been 

reported? This should be answered yes if the study demonstrates that there was a 

comprehensive attempt to measure adverse events. (A list of possible adverse events is 

provided). 

Yes 1 

No 0 
B-31

9. Have the characteristics of patients lost to followup been described? This should be 

answered yes where there were no losses to followup or where losses to followup were so 

small that findings would be unaffected by their inclusion. This should be answered no 

where a study does no report the number of patients lost to followup. 

Yes 1 

No 0 

10. Have 95% CIs and/or actual probability values been reported (e.g. 0.035 rather than 

<0.05) for the main outcomes except where the probability value is less than 0.001 (both 

CI and p value, either CI or p value, neither)? 

Yes 1 

No 0 

External validity 

11. Were the subjects asked to participate in the study representative of the entire 

population from which they were recruited? The study must identify the source 

population for patients and describe how the patients were selected. Patients would be 

representative if they comprised the entire source population, an unselected sample of 

consecutive patients, or a random sample. Random sampling is only feasible where a list of 

all members of the relevant population exists. Where a study does not report the proportion 

of the source population from which the patients are derived, the question should be 

answered as unable to determine. 

Yes 1 

No 0 

Unable to determine 0 

12. Were those subjects who were prepared to participate representative of the entire 

population from which they were recruited? The proportion of those asked who agreed 

should be stated. Validation that the sample was representative would include demonstrating 

that the distribution of the main confounding factors was the same in the study sample and 

the source population. 

Yes 1 

No 0 

Unable to determine 0 
B-32

13. Were the staff, places, and facilities where the patients were treated, representative of 

the treatment the majority of patients receive? For the study to be answered yes the study 

should demonstrate that the intervention was representative of that in use in the source 

population. The question should be answered no if, for example, the intervention was 

undertaken in a specialist center unrepresentative of the hospitals most of the source 

population would attend. 

Yes 1 

No 0 

Unable to determine 0 

Internal validity – bias 

14. Was an attempt made to blind study subjects to the intervention they have received? 

For studies where the patients would have no way of knowing which intervention they 

received, this should be answered yes. 

Yes 1 

No 0 

Unable to determine 0 

15. Was an attempt made to blind those measuring the main outcomes of the intervention?

Yes 1 

No 0 

Unable to determine 0 

16. If any of the results of the study were based on “data dredging”, was this made clear? 

Any analyses that had not been planned at the outset of the study should be clearly indicated. 

If no retrospective unplanned subgroup analyses were reported, then answer yes. 

Yes 1 

No 0 

Unable to determine 0 
B-33

17. In trials and cohort studies, do the analyses adjust for different lengths of followup of 

patients, or in case-control studies, is the time period between the intervention and 

outcome the same for cases and controls? Where followup was the same for all study 

patients that answer should be yes. If different lengths of followup were adjusted for by, for 

example, survival analysis the answer should be yes. Studies where differences in followup 

are ignored should be answered no. 

Yes 1 

No 0 

Unable to determine 0 

18. Were the statistical tests used to assess the main outcomes appropriate? The statistical 

techniques used must be appropriate to the data. For example non-parametric methods 

should be used for small sample sizes. Where little statistical analysis has been undertaken 

but where there is no evidence of bias, the question should be answered yes. If the 

distribution of the data (normal or not) is not described it must be assumed that the estimates 

used were appropriate and the question should be answered yes. 

Yes 1 

No 0 

Unable to determine 0 

19. Was compliance with the interventions reliable? Where there was non compliance with 

the allocated treatment or where there was contamination of one group, the question should 

be answered no. For studies where the effect of any misclassification was likely to bias any 

association to the null, the question should be answered yes. 

Yes 1 

No 0 

Unable to determine 0 

20. Were the main outcome measures used accurate (valid and reliable)? For studies where 

the outcome measured are clearly described, the question should be answered yes. For 

studies which refer to other work or that demonstrates the outcome measures are accurate, 

the question should be answered as yes. 

Yes 1 

No 0 

Unable to determine 0 
B-34

Internal validity – confounding (selection bias) 

21. Were the patients in different intervention groups (trials and cohort studies) or were 

the cases and controls (case-control studies) recruited from the same population? For 

example, patients for all comparison groups should be selected from the same hospital. The 

question should be answered unable to determine for cohort and case-control studies where 

there is no information concerning the source of patients included in the study. 

Yes 1 

No 0 

Unable to determine 0 

22. Were study subjects in different intervention groups (trials and cohort studies) or were 

the cases and controls (case-control studies) recruited over the same period of time? 

For a study which does not specify the time period over which patients were recruited, the 

question should be answered as unable to determine. 

Yes 1 

No 0 

Unable to determine 0 

23. Were the subjects randomized to intervention groups? Studies which state that subjects 

were randomized should be answered yes except where method of randomization would not 

ensure random allocation. For example alternate allocation would score no because it is 

predictable. 

Yes 1 

No 0 

Unable to determine 0 
B-35

24. Was the randomized intervention assignment concealed from both patients and health 

care staff until recruitment was complete and irrevocable? All non-randomized studies 

should be answered no. If assignment was concealed from patients but not from staff, it 

should be answered no. 

Yes 1 

No 0 

Unable to determine 0 

25. Was there adequate adjustment for confounding in the analyses from which the main 

findings were drawn? This question should be answered no for trials if: the main 

conclusions of the study were based on analyses of treatment rather than intention to treat; 

the distribution of known confounders in the different treatment groups was not described; or 

the distribution of known confounders different between the treatment groups but was not 

taken into account in the analyses. In non-randomized studies if the effect of the main 

confounders was not investigated or confounding was demonstrated but no adjustment was 

made in the final analyses the question should be answered as no. 

Yes 1 

No 0 

Unable to determine 0 

26. Were losses to patients to followup take into account? (yes, no, unable to determine) If 

the numbers of patients lost to followup are not reported, the question should be answered as 

unable to determine. If the proportion lost to followup was too small to affect the main 

findings, the question should be answered yes. 

Yes 1 

No 0 

Unable to determine 0 
B-36

Power 

27. Was a power calculation reported for the primary outcome? 

Yes 1 

No 0 

Unable to determine 0 

28. Did the study have sufficient power to detect a clinically important effect where the 

probability value for a difference being due to chance in less than 5%?

Yes 1 

No 0 

Unable to determine 0 
B-37

Form B-3. Assessment of methodology for controlled trials for the 

effectiveness of different methods of toilet training for bowel and 

bladder control 

JADAD SCORE: circle the appropriate response and total for the final Jadad score 

Randomization: 

1. Was the study described as being randomized? 1 = Yes 0 = No 

2. Was the method of randomization appropriate? 1 = Yes 0 = No 

3. Was the method of randomization inadequate? -1 = Yes 0 = No 

Double Blindedness: 

4. Was the study described as double-blind? 1 = Yes 0 = No 

5. Was the method of double-blinding appropriate? 1 = Yes 0 = No 

6. Was the method of double-blinding inadequate? -1 = Yes 0 = No 

Withdrawals: 

7. Was there an adequate description of withdrawals? 1 = Yes 0 = No 

 Total Score: 

CONCEALMENT OF ALLOCATION: was the method used to conceal the randomization list 

[ ] adequate 

[ ] inadequate 

[ ] unclear 
B-38

Form B-4. Data extraction form for the effectiveness of different 

methods of toilet training for bowel and bladder control 

Study Characteristics 

First author: 

Title: 

Journal citation: 

Year published: Country(ies) where conducted: 

Funding: 

 Private industry  Government  Internal  Foundation  Other  NR 

Study design: 

  RCT/CCT  Single cohort  Multiple cohort  Case-control 

  Other _________________ 

Data collection:  Prospective  Retrospective  Can’t tell 

Subject source 

 Community(ies)  Clinic practice 

 Special care facility 

 Other _____________________________ 

Recruitment 

 Random  Consecutive  All eligible 

 Convenience  Special selection (restricted) 

 NR 

Time frame _________________________  NR 

Description of children (inclusion criteria)

 Normal 

 Physically challenged 

  Hirschprung’s  Spina bifida 

  Other _________________________ 

 Mentally challenged 

  Autism 

  ADHD 

  Mix of conditions 

  Other ________________________ 

 NR 

 Readiness screening 

 Other inclusion criteria: 

Cultural background: 
B-39

Toilet training intervention

 Azrin & Foxx  Child-oriented 

 Azrin & Foxx modified  Behavioral therapy 

 Operant conditioning  Other method described in text ____________________ 

Positive reinforcement used:  yes  no  NR 

Negative reinforcement used:  yes  no  NR 

External signalling device used:  yes  no  NR 

Special toileting equipment needed:  yes  no  NR 

Special room needed:  yes  no  NR 

Training objective 

 Daytime bladder control  Daytime bowel control 

 Nighttime bladder control  Nighttime bowel control 

 Both day and nighttime bladder control  Both day and nighttime bowel control 

 Both bladder and bowel control anytime  Improved control 

 Self-directed toileting  Toileting when prompted 

Patient Flow 

1. Initial number selected/screened/eligible: n=___________________  NR 

2. Total agreed to participate: n= _______________________ 

3. Exclusions:  Yes n=_____  No  Unclear  NR 

 Reasons: 

4. Withdrawals/dropouts/refusals:  Yes n=_____  No  Unclear  NR 

 Reasons: 

5. Number who completed the study: n=___________ 

6. Describe comparison group(s) if included: 

Data Collection 

 Questionnaire  Interview  Clinical review  Chart review  Can’t tell 

Baseline Characteristics

Please indicate the statistic (%, SD, SEM, range, AND the units) 

 Group A: __________ 

N ___ 

Group B: _____________ 

N ___ 

All ________ 

N ___ 

Males (n, %) 

 

Age: mean; SD 

 chronological age 

 social age 

 

 

 

Culture/religion/racial 

breakdown 

 
B-40

IQ or VSMS score 

Position in family 

1st child 

2nd or later 

Age TT begun 

SES 

Baseline bladder 

function 

 

Baseline bowel 

function 

 

Other 

Other 

Definition of Success:  NR

Primary Trainer(s):  NA  NR

 Parents Were parents trained prior to implementation?  Yes  No  NR 

 Other care givers Were care givers trained prior to implementation?  Yes  No  NR 

Intervention:  Toilet training program  Drug therapy  Other______________________ 

Describe drug therapy or “other”: 

Describe toilet training program:

 Number of phases: Duration of phases: Duration of TT program: 

 Baseline performance recorded:  Yes  No 

Frequency of diaper/pant (accident) checks: 

 Frequency of toileting: 

 Tracking method in place (i.e.: chart or home visit)  Yes  No 
B-41

Results Reported:  Bladder  Bowel  Both  NR 

For all outcomes specify the units reported in e.g. % change, absolute numbers, incidence/time, etc. 

 Group A: _________ 

N ___ 

Group B: _________ 

N ___ 

All ________ 

N ___ 

Time of measure 

 

 

Change from 

baseline 

 bladder 

 

bowel 

 both

 

Mean # successes 

 

 bladder 

 

bowel 

 both

 

Mean # accidents 

 

 bladder 

 

bowel 

 both

 

Success rate 

Failure rate 

Adverse events 

Additional Comments 
C-42

Appendix C: Multiple Publications of Toilet 

Training Cohorts 

During study screening and data extraction, several articles were identified in which it appeared 

that different outcomes or outcomes at followup were reported for the same cohort of children. 

We did not want either to exclude any relevant results or to over-represent results when the same 

outcome had been reported for a cohort in multiple publications. After critically reviewing the 

references to prior publications and cross-referencing patient demographics, the primary (usually 

the most recent) publication for these cohorts was identified. The cohorts and associated multiple 

publications are described below. 

Linked References Rationale 

Taubman 2003a1*; 

Blum 2004a2

; 

Taumban 2003b3

; 

Blum 20034

; Blum 

20045

Taubman et al. (2003a) examines 406 children who were randomized either to the 

child-oriented approach in combination with avoiding negative terminology to 

describe defecation and praising defecating in diapers or to the child-oriented 

approach alone. The incidence of stool toileting refusal is similar in both groups; 

however, the duration of stool toileting refusal is shorter among the intervention 

group. Blum et al. (2004a) explores factors related to the increasing age at which 

toilet training is successful among the same 406 children and data are analyzed as 

a prospective cohort study; Taubman et al. (2003) is referenced in Blum et al. 

(2004a). Taubman et al. (2003b) examines 408 children, comparing those who hide 

while defecating with those who do not, and the data are analyzed as a case-control 

study. Blum et al. (2003) determines the correlation between age at initiation and 

completion of toilet training and duration of toilet training among 406 children, and 

the data are analyzed as a prospective cohort study. Blum et al. (2004b) follows up 

380 of 406 children, to compare those who develop stool toileting refusal with those 

who do not. The data are analyzed as a case-control study and Taubman (2003a) is 

referenced in Blum et al. (2004b). The reported baseline demographics of the 

individual studies are very similar. 

Hyams 1992 6*; 

Smith 19797 Smith et al. (1979) examines a cohort of 14 severely and profoundly mentally 

handicapped children who were toilet trained with individual intensive regular 

toileting, group intensive regular toileting, or individual timing toileting. Hyams et al. 

(1992) describes a 10-year followup of this cohort and references the original study 

conducted by Smith et al. (1979). 

Van Wagenen 

1969a8

*; Van 

Wagenen 1969b9

Van Wagenen et al. (1969a) describes nine profoundly mentally handicapped 

children who were toilet trained with a forward-moving series of toileting events. Van 

Wagenen et al. (1969b) examines what appear to be the same nine children; the 

data were presented at the 77th Annual APA Convention. 

*primary publication 

Reference List

 1. Taubman B, Blum NJ, Nemeth N. Stool toileting 

refusal: a prospective intervention targeting 

parental behavior. Arch Pediatr Adolesc Med 

2003;157(12):1193-6. 

 2. Blum NJ, Taubman B, Nemeth N. Why is toilet 

training occurring at older ages? A study of 

factors associated with later training. J Pediatr 

2004;145(1):107-11. 

3. Taubman B, Blum NJ, Nemeth N. Children who 

hide while defecating before they have completed 

toilet training: a prospective study. Arch Pediatr 

Adolesc Med 2003;157(12):1190-2. 

 4. Blum NJ, Taubman B, Nemeth N. Relationship 

between age at initiation of toilet training and 

duration of training: a prospective study. 

Pediatrics 2003;111(4):810-4. 

5. Blum NJ, Taubman B, Nemeth N. During toilet 

training, constipation occurs before stool toileting 

refusal. Pediatrics 2004;113(6):e520-2. 
C-43

 6. Hyams G, McCoull K, Smith PS, et al. 

Behavioural continence training in mental 

handicap: a 10-year follow-up study. J Intellect 

Disabil Res 1992;36:551-8. 

7. Smith PS. A comparison of different methods of 

toilet training the mentally handicapped. Behav 

Res Ther 1979;17(1):33-43. 

 8. Van Wagenen RK, Meyerson L, Kerr NJ, et al. 

Field trials of a new procedure for toilet training. 

J Exp Child Psychol 1969;8(1):147-59. 

 9. Van Wagenen R, Keith ML, Kerr NJ, et al. Rapid 

toilet training: learning principles and prothesis. 

Proceedings of the Annual Convention of the 

American Psychological Association 1969;4:781-

2. 
D-44 

Appendix D: Evidence Tables 

 Table D-1. Description of included studies (observational studies) 

 Table D-2. Demographics of included children (observational studies) 

 Table D-3. Description of toilet training programs (observational studies) 

 Table D-4. Description of included studies (trials) 

 Table D-5. Demographics of included children (trials) 

 Table D-6. Description of toilet training programs (trials) 

 Table D-7. Methodological quality of included studies (observational studies) 

 Table D-8. Methodological quality of included studies (trials) 

 Table D-9. Outcomes and results of included studies (observational studies) 

Table D-10. Outcomes and results of included studies (trials) 

References. Observational studies 

References. Trials 
D-45 

Table D-1. Description of included studies (observational studies) 

Author-Year Location Toilet Training Method 1 Toilet Training Method 2 Description of Childre

Healthy Children 

Bakker 2002 

Belgium Other: increased prompting 

and encouraged the child to try later 

Other: less prompting and encouraged child to push or strain 

Healthy 

Brazelton 1962 

United States Child-oriented Healthy 

Butler 1976 

United States Azrin and Foxx Healthy 

Foxx 1973 

United States Azrin and Foxx Healthy 

Kaffman 1972 

Israel Child-oriented Healthy 

Taubman 1997 

United States Child-oriented Healthy 

Mentally Handicapped Children 

Ando 1977 

Japan Operant conditioning Mentally handicapped: au

Colwell 1973 

United States Operant conditioning Mentally handicapped: 

severely and profoundly 

Connolly 1976 

Ireland Operant conditioning Control Mentally handicapped: NR 

Didden 2001 

Netherlands Modified Azrin and Foxx Mentally handicapped: 

Angelman syndrome ± epilepsy 

Giles 1966 

United States Operant conditioning Mentally handicapped: 

severely 

HolverstottCockrell 2002 

United States Azrin and Foxx Mentally and physically 

handicapped: NR 

Kimbrell 1967 

United States Operant conditioning Control Mentally handicapped: 

severely and profoundly 

Lancioni 1980 

Netherlands Modified Azrin and Foxx Mentally handicapped: 

severely (deaf and blind) 

Lancioni 1981a 

Netherlands and Italy 

Other: increased liquids, regular toilet cues, reinforment, and potties in the room 

Other: increased liquids, regular toilet cues, and reinforcement 

Mentally handicapped: auhearing impairment, or profoundly handicapped 

NR indicates not reported
D-46 

Table D-1. Description of included studies (observational studies) (continued) 

Author-Year Location Toilet Training Method 1 Toilet Training Method 2 Description of Childre

Mentally Handicapped Children

Lancioni 1981b 

Netherlands and Italy 

Other: increased liquids, regular toilet cues, positive reinforcement, potties in room 

Other: increased liquids, regular toilet cues, and positive reinforcement 

Mentally handicapped: auhearing impairment, or profoundly handicapped 

Mahoney 1971 

United States Operant conditioning Healthy and mentally 

handicapped 

Smith 1977 

United Kingdom Azrin and Foxx Mentally handicapped: NR 

Spencer 1968 

United States Operant conditioning Mentally handicapped: 

severely and profoundly 

Tierney 1973 

United Kingdom Operant conditioning Control Mentally handicapped: NR 

Van Wagenen 1969 

United States Operant conditioning Mentally handicapped: virt

no speech skills 

Physically Handicapped Children 

Forsythe 1970 

United Kingdom Other: if regular toileting is 

unsuccessful, daily enemas, then enema and suppository, and then enemas and oral purgative 

 Physically handicapped: s

bifida 

King 1994 

United States Other: patient/family education 

and reflex-triggered bowel evacuation 

 Physically handicapped: s

bifida 
D-47 

Table D-1. Description of included studies (observational studies) (continued)

Author-Year Location Toilet Training Method 1 Toilet Training Method 2 Description of Childre

Physically Handicapped Children

Sullivan-Bolyai 1984 

United States Other: stool - diaper/insert 

care, infrequent enemas to disimpact, low-level enemas, suppositories, digital stimulations, bladder - diaper/insert care, penile collectors, urinary diversion, and either timed bladder emptying (± medication) or clean intermittent catherization (± medication) 

 Physically handicapped: s

bifida 

van Kuyk 2000a 

Netherlands Other: teach adequate 

defecation behavior including an adequate straining technique 

 Physically handicapped: a

atresia 

van Kuyk 2000b 

Netherlands Other: teach bowel selfcontrol, training of optimal 

defecation skills, toilet behavior 

 Physically handicapped: 

Hirschprung's disease 
D-48 

Table D-2. Demographics of included children (observational studies) 

Author-Year 

No. of Children 

who Completed 

the study 

Male 

N (%) 

Chronological Age 

(months) 

Developmental or 

Social Age 

(months) 

Baseline Bladder 

Function 

Healthy Children 

Bakker 2002 

4332 2215/4332 

(51) 

138 (6.7)* NR Incontinent: 100% 

Brazelton 1962 

1170 672/1170 

(57) 

~24 NR NR 

Butler 1976 

49 26/49 

(53) 

69% <25 NR Mean frequency of 

accidents: 6.03 (n=32) 

Foxx 1973 

34 22/34 

(65) 

25 (20–36)† NR Mean accidents/day: 6 

Kaffman 1972 

1376 721/1376 

(52) 

15–26 (range) 

NR Incontinent: 100% 

Taubman 1997 

482 255/482 

(53) 

NR NR NR 

Mentally Handicapped Children 

Ando 1977 

5 5/5 

(100) 

86.4 (13.2)* NR NR 

Colwell 1973 

47 30/47 

(64) 

108 (32.4)* 16.7 (6.2)* NR 

Connolly 1976 

13 NR 84.8 

(mean) 

NR Wettings/wk: 57 

Didden 2001 

6 NR 132 (72–228)† NR Frequency of incorrect 

toileting: 1.7 (1.76)* 

Giles 1966 

5 5/5 

(100) 

122.4 (56.4)* 21.2 (5.4)* NR 

HolverstottCockrell 2002 

9 7/9 

(78) 

46.68 (10.2)* NR Accidents/day (type not 

specified): 1.64 (0–3) †

Kimbrell 1967 

40 0/40 

(0) 

139.5 (109.5–173.2) † 16.8 (10.8–24.8) † NR 

NR indicates not reported; SD: standard deviation; wk: week *mean, SD †mean, range 
D-49 

Table D-2. Demographics of included children (observational studies) (continued) 

Author-Year 

No. of Children 

who Completed 

the Study 

Male 

N (%) 

Chronological Age 

(months) 

Developmental or 

Social Age 

(months) 

Baseline Bladder 

Function 

Mentally Handicapped Children

Lancioni 1980 

9 3/9 

(33) 

171.6 (97.2–195.6) † NR Independent toileting: 0% 

Lancioni 1981a 

5 3/5 

(60) 

150 (129.6–175.2) † NR Accidents/day: 1.25 

(range 0–3) †

Lancioni 1981b 

5 3/5 

(60) 

150 (129.6–175.2) † NR NR 

Mahoney 1971 

8 7/8 

(88) 

44.9 (29.1)* NR Urinate on floor or in pants 

during 5 1-hour sessions: 15.5 (6.02)* 

Smith 1977 

13 NR 126 (48)* 22.4 (5.5)* Mean accidents/wk: 51.88 

(2.59)* 

Spencer 1968 

38 38/38 

(100) 

102 (48–144) † 18 (4–39) † NR 

Tierney 1973 

36 28/36 

(78) 

138 (60–252) † 4.2–22.6 

(range) 

NR 

Van Wagenen 1969 

8 5/9 

(55) 

6.1 (1.7)* NR Number who always 

urinated through cotton brief and on the floor: 7/9 

Physically Handicapped Children 

Forsythe 1970 

47 28/47 

(60) 

24–120 (range) 

NR NR 

King 1994 

35 NR 18–348 

(range) 

NR NR 

Sullivan-Bolyai 1984 

Stool training =225 Bladder training =215 

NR 12–216 and older NR NR 

van Kuyk 2000a 

43 27/43 

(63) 

108 (48.1)* NR NR 

van Kuyk 2000b 

16 16/16 

(100) 

81.6 (45.6)* NR NR 

*mean, SD †mean, range 
D-50 

Table D-3. Description of toilet training programs (observational studies) 

AuthorYear Toilet Training Objective Readiness Screening Trainers Toilet Training Methods Description of Toilet Training Methods Reinforc

Healthy Children 

Bakker 2002 

Bladder and bowel control anytime 

NR Parents Other: NR 

Other: NR 

Other: increased prompting and encouraged the child to try again later when he could not void Other: less prompting and encouraged child to push or strain, make encouraging noises, or open a tap 

Positive apunishme

Brazelton 1962 

Daytime and nighttime bladder control 

No Parents Child-oriented: 

Brazelton 1962 

Child oriented: original childorientated approach NR 

Butler 1976 

Daytime bladder and bowel control 

NR Parents Azrin and Foxx: Azrin 

1974 

Azrin and Foxx: toilet training in less than a day 

NR 

Foxx 1973 

Self-directed daytime bladder and bowel control 

Yes Adult 

assistants 

Azrin and Foxx: Azrin 1971; Azrin 1973 

Azrin and Foxx: provided an intensive learning experience that maximized the factors known to be important for learning, then faded out these factors once learning occurred 

Positive apunishme

Kaffman 1972 

Daytime and nighttime bladder control 

NR Caregivers 

and parents 

Child-oriented: NR Child-oriented: begun at the 

discretion of the trained caregivers and assisted by at least 6 others. Readiness based on neuromuscular and intellectual development level and child’s will for mastery and cooperation. Process geared to minimize conflict and reduce anxiety in presence of accidents or persistent failure 

Positive 

Taubman 1997 

Self-directed daytime bowel and bladder control 

No Parent Child-oriented: 

Brazelton 1962 

Child-oriented: began training at ~2 yr.unless the child independently demonstrated an interest at an early age, using a child-oriented approach, positive reinforcement, and patience. Parents were cautioned against using a coercive approach 

Positive 

h indicates hour; ml: milliliters; mo: month; NR: not reported; VSMS: Vineland social maturity scale; yr: year
D-51 

Table D-3. Description of toilet training programs (observational studies) (continued) 

AuthorYear Toilet Training Objective Readiness Screening Trainers Toilet Training Methods Description of Toilet Training Methods Reinforc

Mentally Handicapped Children 

Ando 1977 

Self-directed daytime bladder control 

NR Caregivers Operant conditioning: NR Operant conditioning: positively 

reinforced with candy and praise; negatively reinforced with physical violence, removing wet pants, and taking them to the cleaning receptacle 

Positive apunishme

Colwell 1973 

Prompted bladder and bowel control anytime 

NR Nonprofessional 

staff 

Operant conditioning: NR Operant conditioning: trained in 

self-help skills that include toileting; training was generally based on operant procedures 

Positive 

Connolly 1976 

Daytime bowel and bladder control 

NR Caregivers Operant conditioning: NR 

Control: NR 

Operant conditioning: verbally praised for accident-free occasions and successful toileting Control: toileted as before 

Positive 

Didden 2001 

Prompted bladder and bowel control anytime 

NR Caregivers Modified Azrin and Foxx: 

Azrin 1971 

Modified Azrin and Foxx: modifications included establishing prompted toileting rather than selfinitiated, no potty or pants alarms, time out from positive reinforcement was used immediately following restitutional over correction, positive practice was omitted due to participants’ motor limitations, and fluid intake was restricted to 70 ml/h 

Positive apunishme

Giles 1966 

Self-directed daytime bowel control 

No Attendants Operant conditioning: 

Ellis 1963 

Operant conditioning: combination of methods using operant behavior modification 

Positive apunishme
D-52 

Table D-3. Description of toilet training programs (observational studies) (continued)

AuthorYear Toilet Training Objective Readiness Screening Trainers Toilet Training Methods Description of Toilet Training Methods Reinforc

Mentally Handicapped Children

Holverstott-Cockrell 2002 

Daytime bladder and bowel control 

No Parents, 

teachers, aides 

Modified Azrin and Foxx: Holverstott-Cockrell 1997 

Modified Azrin and Foxx: training program involved the use of positive reinforcement, data collection, training pants, Big Kid coloring book, and dry pants checks 

Positive 

Kimbrell 1967 

Prompted daytime bladder and bowel control 

NR Attendants Operant conditioning: 

Ellis 1963; Roos 1965 Control: NR 

Operant conditioning: an operant conditioning program to improve behavior in several areas, including toileting Control: usual care 

Positive 

Lancioni 1980 

Self-directed daytime bladder control 

NR Teachers, 

caregivers, psychologist 

Modified Azrin and Foxx: Azrin 1971 

Modified Azrin and Foxx: used potty and pants alerts, increased liquids, food reduction, positive/negative reinforcement, limitation of environmental stimulation, and distance fading 

Positive apunishme

Lancioni 1981a 

Self-directed daytime bladder control 

NR Teachers, 

teacher assistants 

Other: NR Other: NR 

Other: increased liquids, regular toilet cues, positive and negative rienforcment; 25 potties placed throughout the room that were phased out as child progressed Other: increased liquids, regular toilet cues, positive and negative reinforcement 

Positive apunishme

Lancioni 1981b 

Self-directed daytime bladder control 

NR Teachers, 

teacher assistants 

Other: NR Other: NR 

Other: increased liquids, regular toilet cues, and positive reinforcement; 25 potties placed throughout the room that were phased out as child progressed Other: increased liquids, regular toilet cues, positive reinforcement 

Positive apunishme
D-53 

Table D-3. Description of toilet training programs (observational studies) (continued) 

AuthorYear Toilet Training Objective Readiness Screening Trainers Toilet Training Methods Description of Toilet Training Methods Reinforc

Mentally Handicapped Children

Mahoney 1971 

Prompted daytime bladder control 

NR Caregivers Operant conditioning: NR Operant conditioning: response to 

auditory signal 

Positive apunishme

Smith 1977 

Daytime toilet training 

NR NR Azrin and Foxx: Azrin 

1973 

Azrin and Foxx: increased fluids, use of urine-sensitive equipment, combination of operant techniques 

Positive apunishme

Spencer 1968 

Daytime bladder and bowel control 

NR Attendants Operant conditioning: 

NR 

Operant conditioning: children placed on commode 3–7 times a day at usual voiding times Untrained subjects were rewarded for both sitting on the commode and again for voiding in it Subjects who were incontinent <50% of the time were only rewarded for voiding in the commode 

Positive 

Tierney 1973 

Self-directed daytime bladder and bowel control 

NR Nurses Operant conditioning: 

NR Control: NR 

Operant conditioning: all incontinence and toilet behavior was observed and recorded; all appropriate behavior was reinforced; all inappropriate behavior was ignored Control: toileted as before 

Positive 

Van Wagenen 1969 

Self-directed daytime bladder control 

NR Experimenter Operant conditioning: 

Van Wagenen 1966 

Operant conditioning: liquid was increased and child wore an auditory signal generator that sounded when the child voided. After the signal, the trainer said ‘no’, took child by hand to toilet and placed in appropriate position If the child continued to void, he wasrewarded. If successful, the signal device was replaced with training pants and the child was taught to remove and replace them to void 

Positive apunishme
D-54 

Table D-3. Description of toilet training programs (observational studies) (continued) 

AuthorYear Toilet Training Objective Readiness Screening Trainers Toilet Training Methods Description of Toilet Training Methods Reinforc

Physically Handicapped Children 

Forsythe 1970 

Daytime bowel control 

NR NR Other: Deaver 1953 Other: regular toileting post 

evening meal for 2 mo. If unsuccessful, daily enemas until empty then regular toileting resumed. If unsuccessful, enema plus daily suppository, and if still unsuccessful, enemas plus oral purgative 

NR 

King 1994 

Daytime and nighttime bowel control 

NR Psychiatrist, 

family members, child 

Other: NR Other: patient/family education and 

a regular, consistently timed, reflex-triggered bowel evacuation 

No 
D-55 

Table D-3. Description of toilet training programs (observational studies) (continued) 

AuthorYear Toilet Training Objective Readiness Screening Trainers Toilet Training Methods Description of Toilet Training Methods Reinforc

Physically Handicapped Children

SullivanBolyai 1984 

Self-directed and prompted bladder and bowel control anytime 

NR Parent/ 

guardian 

Other: Chapman 1979 Other: stool training method; < 

3yr.1) timed, 2) suppository, 3)expansion enema, 4) diaper care; ≥ 4yr.1) timed with digital stimulation, 2) suppository, 3) xpansion enema, 4) untimed diaper or pant insert, 5) infrequent enema. Bladder training method: < 6 yr.1) timed, 2) clean intermittent catheterization, 3) diaper/pant insert; ≥ 6yr.1) heat diversion, 2) timed, 3) clean intermittent catheterization, 4) diaper/pant insert, 5) penile collector OR Stool training included: diaper/insert care, infrequent enemas to disimpact, low-level enemas, suppositories, digital stimulations; Bladder training included diaper/insert care, penile collectors, urinary diversion, and timed bladder emptying ± medication, or clean intermittent catherization ± medication 

NR 

van Kuyk 2000a 

Daytime and nighttime bowel control 

NR Psychologist 

and/or parents and/or physiotherapist and/or surgeon 

Other: van Kuyk 2000 Other: behavioral program to teach 

children and their parents adequate defecation behavior including an adequate straining technique 

No 

van Kuyk 2000b 

Self-directed daytime and nighttime bowel control 

No Child, 

psychologist, parents 

Other: NR Other: teaching the child bowel 

self-control, training of optimal defecation skills and, subsequently, toilet behavior 

Positive 
D-56 

Table D-4. Description of the toilet training programs (trials) 

Author-Year Location Toilet Training Intervention 1 Toilet Training Intervention 2 Toilet Training Intervention 3 Description of C

Healthy Children 

Candelor 1977 

United States Azrin and Foxx Other: Spock's Baby and 

Childcare Handbook 

 Healthy 

Matson 1977 

United States Azrin and Foxx with 

supervision 

Azrin and Foxx without supervision 

 Healthy 

Taubman 2003 

United States Child-oriented and 

handbook promoting praising defecation 

Child-oriented Healthy 

Mentally Handicapped Children 

Edgar 1975 

United States Other: relaxation-tension 

exercise regimen 

Other: played with toys, given individual attention, and placed on toilet 

 Mentally handica

severely and pro

Hundziak 1965 

United States Operant conditioning Other: toileted several 

times a day, scolded for soiling, praised for successful toileting 

Control Mentally handica

severely 

Hyams 1992 

United Kingdom 

Individual-modified Azrin and Foxx 

Group-modified Azrin and Foxx 

Other: intensive individual training program where the child is prompted and rewarded for successful toileting 

Mentally handicaseverely and pro

Sadler 1977 

United States Azrin& Foxx Other: toileted on a 

schedule 

Control Mentally handica

severely and pro

Physcially Handicapped Children 

van Kuyk 2001 

Netherlands Operant conditioning Other: standard medical 

treatment 

 Physically handic

Hirschprung's 
D-57 

Table D-5. Demographics of included children (trials) 

Author-Year 

No. of Children 

who Completed 

the Study 

Male 

N (%) 

Chronological Age 

(months) 

Developmental 

or Social Age 

(months) 

Baseline Bladder 

Function 

Healthy Children 

Candelora 1977 

71 44/71 

(62) 

26.11 (18-35) † NR Mean 

accidents/day/child: 4.59 

NR 

Matson 1977 9 7/10 

(70) 

20-26 (range) 

NR NR NR 

Taubman 2003 

381 197/381 

(completed) (52) 

17-19 (range) 

NR Incontinent: 100% Inco

Mentally Handicapped Children 

Edgar 1975 

20 NR 48-144 

(range) 

19.5 (15-23) † NR NR 

Hundziak 1965 

26 26/26 

(completed) (100) 

NR 84–168 

(range) 

NR NR 

Hyams 1992 

14 5/15 

(33%) 

135 (68– 224) † 22.3 (11-26) † NR NR 

Sadler 1977 

14 11/14 

(79) 

84–144 (range) 

NR Mean wets/child/day: 

0.88–1.00 (range of group means) 

NR 

Physically Handicapped Children 

van Kuyk 2001 

25 21/27 

(78) 

62.4 (24–132) † NR Parental judgment on 

Bowel Incontinence Scale: 17.4 (7.6)

*

% fe(35

NR indicates not reported; SD: standard deviation *mean, SD †mean, range 
D-58 

Table D-6. Description of the toilet training programs (trials) 

Author-Year Toilet Training Objective Readiness Screening Toilet Trainers Toilet Training Methods Description of Toilet Training Methods Reinforcem

Healthy Children 

Candelora 1977 

Self-directed daytime bladder control 

Yes Parents Azrin and Foxx: 

Azrin 1974 Other: Spock 1986 

Azrin and Foxx: toilet training in less than a day Other: baby and childcare handbook that describes developmental highlights, readiness indications, specific training procedures, and expected problems associated with bladder and bowel training 

NR 

Matson 1977 

Daytime bladder control 

Yes Parents ± 

supervisors 

Azrin and Foxx: Azrin 1974 Azrin and Foxx: Azrin 1974 

Azrin and Foxx: toilet training in less than a day with mothers supervised by an experienced trainer Azrin and Foxx: toilet training in less than a day with mothers unsupervised 

NR 

Taubman 2003 

Self-directed daytime bladder and bowel control 

NR Parents Child-oriented: 

AAP 1999; Stadtler 1999 

Other: received handout describing child-oriented approach to TT, increased praise for defecating in diaper before TT begins, and not using negative terms for stool or defecating Child oriented: received handout describing childoriented approach to TT 

Positive 

NR indicates not reported; TT: toilet training; wk: week 
D-59 

Table D-6. Description of the toilet training programs (trials) (continued) 

Author-Year Toilet Training Objective Readiness Screening Toilet Trainers Toilet Training Methods Description of Toilet Training Methods Reinforc

Mentally Handicapped Children 

Edgar 1975 

Self-directed and when prompted daytime bladder control 

No Caregivers Other: Kephart 

1969 Other: NR 

Other: all wore urinary training devices; experimental group: increased fluids followed by relaxation-tension exercise regimen 15 min later then placed on toilet (regeimen = massage, shaking, stretching) Other: all wore urinary alarm devices; controls played with toys, given individual attention, and placed on toilet 

Positive anpunishmen

Hundziak 1965 

Daytime and nighttime bladder control 

No Caregivers Operant 

conditioning: Ellis, 1963 Other: NR Control: NR 

Operant conditioning: used a candy dispensing device to positively reward and reinforce eliminative responses Other: children taken to the bathroom several times a day, scolded for soiling and praised for successful use of bathroom facilities Control: no organized routine was maintained to subject the children to a toilet training program 

Positive 
D-60 

Table D-6. Description of the toilet training programs (trials) (continued) 

Author-Year Toilet Training Objective Readiness Screening Toilet Trainers Toilet Training Methods Description of Toilet Training Methods Reinforc

Mentally Handicapped Children

Hyams 1992 

Self-directed daytime bladder control 

NR Nurses Modified Azrin 

and Foxx: Azrin 1971; Azrin 1973 Modified Azrin and Foxx: NR Other: Mahoney 1971; Van Wagenen 1969 

Modified Azrin and Foxx: intensive, individual regular potting training program where accidents resulted in a reprimand and timeout from reward for 10 minutes. All groups used pants and toilet alarms Modified Azrin and Fox: training procedures similar to above, but trained in a group Other: intensive individual training program where the child is prompted and rewarded after successful toileting 

Positive anpunishmen

Sadler 1977 

Daytime bladder control 

NR Staff Azrin& Foxx: Azrin 

1971; Azrin 1973 Other: NR Control: NR 

Azrin and Foxx: over correction and repeated positive practice Other: scheduling method where children are toileted 4 times a day Control: no training 

Positive anpunishmen
D-61 

Table D-6. Description of the toilet training programs (trials) (continued)

Author-Year Toilet Training Objective Readiness Screening Toilet Trainers Toilet Training Methods Description of Toilet Training Methods Reinforc

Physically Handicapped Children 

van Kuyk 2001 

Daytime and nighttime bladder control 

NR Child, parents, 

psychologist, and physiotherapist 

Operant conditioning: van Kuyk 2000 Other: NR 

Operant conditioning: biopsychosocial approach to extinguish defecation anxiety and avoidance behavior by teaching bowel selfcontrol via optimal defecation skills and toilet behavior Other: put on a waiting list and received standard medical treatment consisting of laxatives, enemas, or bowel rinsing 

Positive 
D-62 

Table D-7. Methodological quality of included studies (observational studies) 

Author-Year Study Design Downs and Black Score Data Collection Data Collection Methods Funding 

Ando 1977 

Single cohort 16 Prospective Clinical review Government, 

foundation 

Bakker 2002 

Multiple cohort 21 Retrospective Questionnaire NR 

Brazelton 1962 

Single cohort 13 Retrospective Chart review NR 

Butler 1976 

Single cohort 11 Prospective Other NR 

Colwell 1973 

Single cohort 22 Unclear Clinical review NR 

Connolly 1976 

Single cohort 17 NR Clinical review NR 

Didden 2001 

Single cohort 17 Prospective Clinical review NR 

Forsythe 1970 

Single cohort 15 Retrospective NR Industry 

Foxx 1973 

Single cohort 18 Prospective NR Government 

Giles 1966 

Single cohort 15 Prospective NR NR 

HolverstottCockrell 2002 

Multiple cohort 19 Prospective Questionnaire NR 

Kaffman 1972 

Single cohort 16 Retrospective Other NR 

Kimbrell 1967 

Multiple cohort 17 Prospective Clinical review NR 

King 1994 

Single cohort 21 Retrospective Chart review NR 

Lancioni 1980 

Multiple cohort 16 Prospective Clinical review NR 

Lancioni 1981a 

Single cohort 16 Prospective Other Other 

Lancioni 1981b 

Single cohort 16 Prospective Other Other 

Mahoney 1971 

Single cohort 15 NR Clinical review NR 

Smith 1977 

Multiple cohort 18 Retrospective Chart review NR 

NR indicates not reported 
D-63 

Table D-7. Methodological quality of included studies (observational studies) (continued)

Author-Year Study Design Downs and Black Score Data Collection Data Collection Methods Funding 

Spencer 1968 

Single cohort 18 Prospective Clinical review NR 

SullivanBolyai 1984 Single cohort 18 Retrospective Clinical review Foundation Taubman 1997 

Single cohort 20 Prospective Interview NR 

Tierney 1973 

Multiple cohort 16 Prospective Clinical review NR 

van Kuyk 2000a 

Single cohort 22 Retrospective Chart review NR 

van Kuyk 2000b 

Single cohort 20 Retrospective Questionnaire NR 

Van Wagenen 1969 

Single cohort 13 Prospective Clinical review Other 
D-64 

Table D-8. Methodological quality of included studies (trials)

Author-Year Jadad Score Allocation Concealment Data Collection Method Funding Source 

Candelora 1977 

2 Unclear Questionnaire NR 

Edgar 1975 

2 Unclear Clinical review Government 

Hundziak  1965 

2 Unclear Clinical review Government 

Hyams 1992 

2 Unclear Interview NR 

Matson 1977 

2 Unclear Clinical review Internal 

Sadler 1977 

2 Unclear Other NR 

Taubman 2003 

2 Unclear Interview Government 

van Kuyk 2001 

1 Unclear Clinical review Government 

NR indicates not reported 
D-65 

Table D-9. Outcomes and results of included studies (observational studies) 

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Healthy children 

Bakker 2002 

Other: Increased prompting v. less prompting 

Retrospective cohort 

Residual lower urinary tract symptoms (LUTS) at ≥10 yr 

Comparisons based on sex, family structure, number of bedwettingrelatives, school performance, selfmanagement, daily hygiene, age TT begun, parent attitudes 

N=4332 928/4332 (21%) symptomatic at 10 to 14 yr. Symptom group v. control: significant difference in: 1. Proportion female (62.1% v. 45.2%) 2. Fewer from stable first marriage (82% 

v. 86%) 

3. Bedwetting relatives (37% v. 25%) 4. Poorer school performance (12% v. 

8%) 

5. Less ability to manage homework and 

appointments independently (73% v. 68%) 

6. Less capacity to manage daily hygiene 

(37% v. 31%) 

7. Began TT at older age (22% v. 32% 

began TT before 18 mo) 

8. Parents in symptom group used less 

prompting, were more liberal, rewarded and punished more, and exerted more pressure if attempt to 

void failed 

Brazelton 1962 

Child-oriented Retrospective 

cohort 

Age, day, and nighttime bladder continence 

Comparisons based on sex 

N=1170 

Day training achieved 1–2 mo later and nighttime 1–7 mo longer in 1st child 

54.7% began TT at 24 mo 12.3% achieved bowel training first 

8.2% bladder, and 79.5 % simultaneous 

training 

80.7% daytime trained by average 28.5 

mo and 80.3% night trained by 3 yr.Average age to complete all training was 33.3 mo; males took 2.3 mo longer to complete 

1.4% had residual problems >5 yr 

CG indicates conventional group; CIC: clean intermittent catheterization; LUTS: lower urinary tract symptoms; MC: mentally handicapped childroperant conditioning; RT: regular toileting; SA: social age; SI: self-initiated; SIE: self-initiated elimination; STR: stool toileting refusal; TT: toilet t

VSMS: Vineland social maturity scale; wk: week; yr: year; ↑: increased; ↓: decreased 
D-66 

Table D-9. Outcomes and results of included studies (observational studies) (continued)

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Healthy Children 

Butler 1976 

Azrin and Foxx Prospective 

cohort 

Bowel and bladder accidents 

Comparisons based on sex and age 

N=49 End 1st intensive training session 

<25 mos: 25/34 (74%) success >25 mos: 14/15 (93%) success 

Mean intensive training time: all =4.5 hr (range 1.25–10) 

<25 mo.= 5.15 hr >25 mo.= 4.08 hr 

2 wk post training: mean # accidents 

bladder ↓ 6.03 to 0.60/day (p<0.001) bowel ↓ 1.23 to 0.07/day 3 failures: 2 male, 1 female 

8 wk post training: mean # accidents 

bladder = 0.58/day bowel = 0.11/day 2 failures: 1 male, 1 female 

Foxx 1973 

Azrin and Foxx Prospective 

cohort 

Self toileting without reminders 

Bowel and bladder accidents, training time 

N=34 (results at 1–4 mos) 33/34 (97%) success 

Mean no. accidents/day: pre-training / 1 day post- training / 4 mo. post training 

Bladder: ~6 / ~0.5 (↓of 97%) / ~0 Mean training time: 3.9 hr (range 0.5–14) 

26–36 mo. = 2.25 hr 20–25 mo. = 5 hr 

1/34 regressed at 3 mo. followup 

Kaffman 1972 

Child-oriented Retrospective 

cohort 

Enuresis Comparisons by 

age and sex 

N=1376 TT begun at 15–26 mo. Proportion enuretic: 

4–15 yr: 13.9%; M/F = 14.9/12.8% 4–7 yr: 133/508 (26%); M/F = 13/13% 7–15 yr: 59/868 (7%) M/F = 5/2% 
D-67 

Table D-9. Outcomes and results of included studies (observational studies) (continued)

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Healthy and Mentally Handicapped Children 

Mahoney 1971 

Operant conditioning Prospective 

cohort 

Level of performance from 1–10 where Level 10 = independent toileting 

Number of training hours Number of trials 

Healthy: n=3; MC n=5 (results after 29 hrs of training) Healthy: 3/3 (100%) attained Level 10 

over average of 29 hr and 118 trials. 

MC: 4/5 (80%) attained Level 10 over 

average 29 hrs and 262 trials 

1 failure 

Taubman 1997 

Child-orientated Prospective 

cohort 

Stool toileting refusal (STR) 

Associated factors 

N=482 ≤ 3 yr: 292/482 (61%) trained 4 yr: 471/482 (98%) trained 22% experienced ≥ 1 mo of STR, 73% 

resolved without intervention 

STR significantly associated with 

presence of younger siblings, parental inability to set limits, and later age (>42 mo.) to complete TT 

Overall: 48% males and 30% females 

trained by 3 yr.(p=0.0004) 

48% began TT < 24 mo.and 32% not 

trained until >3 yr 

52% begun TT > 24 mo.and 46% not 

trained until > 3yr 

No association between age of TT with 

mother’s work status, attending daycare, behavior scores, or presence of siblings 

STR group 

Age STR began: 73% between 24–36 mos Siblings: 33% had younger and 17% had older Behavior scores: ≤ 2 = 32% with STR, 

> 2 = 20% with STR 
D-68 

Table D-9. Outcomes and results of included studies (observational studies) (continued)

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Physically Handicapped Children 

Forsythe 1970 

Other: progressive intervention if unsuccessful bowel control 

Prospective cohort 

Independent bowel control 

 N=47 

Bowel control obtained: 1. Regular toileting (RT) 

8/47 (17%) maintained >2 yr 8 others relapsed at 8–15 mo. 

2. Enemas + RT 

7/39 (18%) maintained >2 yr 2 others relapsed at 6–8 mo. 

1 & 2 combined 

15/47 (32%) success 10/47 (21%) temporary improvement 22/47 (47%) unchanged 

3. Enemas + RT + suppositories 

Glycerin: 0/25 (0%) success Dulcolax: 3/25 (12%) Stopped dulcolax at 6 mo. Maintained for 2 yr. 18/25 (72%) relapsed 3 mo. after enemas stopped Micralax micro-enemas 2/22 (8%) success Stopped tx at 6 mo. Maintained >2 yr 20/25 (80%) unchanged 

4. Enemas + RT + purgatives 

Dulcodos: 8/16 (50%) Maintained >9 mo. Senokot syrup: 15 /15 (100%) Maintained >6 mo. 
D-69 

Table D-9. Outcomes and results of included studies (observational studies) (continued)

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Physically Handicapped Children

King 1994 

Other: patient and family education and regular reflextriggered bowel evacuation 

Retrospective cohort 

Bowel continence Comparisons 

based on age, compliance, and reflexes present 

N=35 Bowel continence ↑ from 0 to 54.3% 24/35 (68.6%) were compliant; 19/24 (79%) of these became continent Reflexes present 

Anocutaneous reflex: 8/8 (100%) with reflex became continent 

10/25 (40%) without reflex did not Bulbocavernosus reflex: 13/19 (68%) with reflex became continent 5/14 (36%) without reflex did not 

Age 

≤ 6 yr: 11/17 (65) became continent >6 yr: 8/18 (44%) became continent 

SullivanBolyal 1984 

Other: bowel training 1. untimed random 

collection with diaper or insert 

2. infrequent enema 3.small rapid low 

level enema 

4. suppositories 5. timed evacuation ± 

digital stimulation 

bladder training 1.diaper/pant insert + 

periodic cleansing. 

2. penile collector 3. urinary diversion 4. timed emptying ± 

medication 

5. clean intermittent 

catheterization (CIC) ± medication

Retrospective cohort 

Dependent and independent toileting Socially acceptable and unacceptable toileting 

Comparisons based on sex, IQ, and training method 

N=525 High lumbar/thoracic lesions: 80% 

became socially acceptable by 16–17 yr; 50% were dependent 

Low lumbar/sacral lesions: 80% became 

socially acceptable by 10–11yr 

50% were dependent 

All levels: 50% became socially 

acceptable between 7–9 yr 

70% were dependent 

No differences based on age, sex, or 

time TT begun 

IQ <69: 1/30 successful Bowels: <3 yr: n=41 Socially acceptable/dependent: 39/41 

(95%) 7/41 (17%) timed evacuation 14/41 (35%) Bisacodyl suppository 3/41 (7%) expansion enema 

15/41 (41%) diapers 
D-70 

Table D-9. Outcomes and results of included studies (observational studies) (continued)

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Physically Handicapped Children

SullivanBolyai 1984

Socially unacceptable/dependent: 2/41 (5%) > 4 yr: n=184 Socially acceptable/independent: 84/184 

(46%) 

 55/184 (30%) timed evacuation  24/184 (13%) bisacodyl suppository  3/184 (2%) small expansion enemas 

1/184 (.005%) diaper/pant insert 1/184 (.005%) infrequent enema 

Socially acceptable/dependent: 57/184 

(31%) 18/184 (10%) timed evacuation (3/18 (17%) with digital stimulation) 24/184 (13%) bisacodyl suppository 12/184 (7%) expansion enemas 2/184 (1%) diaper/pant insert 

1/184 (0.005%) infrequent enema 

Socially unacceptable/dependent: 

23/184 (13%) 

Socially unacceptable/independent: 

19/184 (10%) 

Bladder: < 6yr: n=57 Socially acceptable/dependent: 45/57 

(79%) 3/57 (5%) timed 10/57 (18%) CIC 32/57 (56%) diaper/pant insert 

Socially acceptable/independent: 

1/57(2%) 1/57 (2%) CIC 

Socially unacceptable/dependent: 

11/57 (19%) 

> 6 yr: n=158 
D-71 

Table D-9. Outcomes and results of included studies (observational studies) (continued) 

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Physically Handicapped Children

SullivanBolyai 1984 

 Socially acceptable/dependent: 52/158 

(33%) 23/158 (15%) heat diversion 4/158 (3%) timed evacuation 12/158 (8%) CIC 2/158 (0.01%) diaper/pant insert 11/158 (7%) penile collectors 

Socially acceptable/independent: 55/158 

(35%): 27/158 (17%) heat diversion 8/158 (5%) timed evacuation 10/158 (6%) CIC 1/158 (0.01%) diaper/pant insert 9/158 (6%) penile collectors 

Socially unacceptable/dependent: 

36/158 (23%) 

Socially unacceptable/independent: 

51/158 (32%) 

van Kuyk, 2000a 

Operant conditioning Retrospective 

cohort 

Bowel continence (Templeton and Wingspread scores) Constipation Defecation behavior 

Comparisons based on age 

N=16 14/16 (88%) achieved good continence 12/16 (75%) were clean 8/12 (67%) recovered from constipation Templeton score: ↓ from 2.7 ± 0.48 to 1.1 

± 0.34 (p=0.00) 

Wingspread score: ↓ from 3.5 ± 0.52 to 

1.3 ± 0.60 (p=0.00) 

Constipation: ↓ from 1.8 ± 0.45 to 1.3 ± 

0.45 (p=0.01) 

Defecation behavior: ↓ from 2.9 ± 0.34 to 

1.1 ± 0.34 (p=0.00) 

No difference based on age 
D-72 

Table D-9. Outcomes and results of included studies (observational studies) (continued)

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Physically Handicapped Children

van Kuyk 2000b 

Operant conditioning Retrospective 

cohort 

Feces in toilet Number of days without soiling Templeton score Wingspread score Constipation score Parental judgment incontinence scales 

Comparisons based on age and high v. lower anal atresia 

N=43 

17/43 (40%) achieved good continence 21/43 (49%) achieved fair continence 51% were clean 40% only staining 10/18 (55%) recovered from constipation 

Templeton score: ↓ from 2.7 ± 0.45 to 1.6 

± 0.59 (p=0.00) 

Wingspread score: ↓ from 3.4 ± 0.85 to 

2.2 ± 0.80 (p=0.00) 

Constipation: ↓ from 1.5 ± 0.51 to 1.2 ± 

0.41 (p=0.01) 

Defecation behavior: ↓ from 2.8 ± 0.39 to 

1.4 ± 0.55 (p=0.00) 

Straining technique: ↓ from 2.5 ± 0.67 to 

1.2 ± 0.43 (p=0.00) 

No difference based on age 

Mentally Handicapped Children 

Ando 1977 

Operant conditioning Prospective 

cohort 

Self-initiated elimination 

 N=5 

4/5 (80%) achieved improved selfinitiated elimination (SIE): 

1 improved SIE by 50% in 11 mos 1 improved SIE by 60% in 3 mos 1 improved SIE by 32% in 3 mos 1 improved SIE by 18% in 12 mos 1 made no progress 

None completely eliminated 

inappropriate urination 

Better result in those with some receptive 

language skills 
D-73 

Table D-9. Outcomes and results of included studies (observational studies) (continued)

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Mentally Handicapped Children 

Colwell 1973 

Operant conditioning Prospective 

cohort 

Toileting skills under verbal control (top score 18) 

Dressing skills Feeding skills Mental age 

N=47 (results achieved in ~ 7.1 mos) Mean toileting score ↑ from 6.0 ± 4.7 to 

10.0 ± 4.7 (p<0.001) 

33/47 (70%) made gains 8/47 (17%) made no gains 3/47 (6%) regressed from baseline 

Connolly 1976 

Operant conditioning Prospective 

cohort 

Wetting incidents Soiling incidents Successful toileting following accident free period 

 N=9 

(results at 7 wk followup) Wetting accidents ↓ 14% and soiling 

accidents ↓ 25% 

2/9 (22%) were successfully trained Successful toileting following accident 

free period periods continued to decrease 

Didden 2001 

Azrin and Foxx (modified) 

Prospective cohort 

Accidents and correct toileting/day and at 2.5 yr.post training followup 

Time spent training 

N=6 (results at 2.5 yr.followup) Mean incorrect toileting/day ↓ from 1.65 

± 1.76 to 0.12 ± 0.29 at followup (p=0.07) 

Mean correct toileting/day ↑ from 0.80 ± 

0.95 to 3.1 ± 1.57 (p=0.02) 

Mean TT time was 17.2 days (range 12–

25) and 108 ± 31 hrs 

Giles 1966 

Operant conditioning Prospective 

cohort 

Consistent selfinitiated (SI) bowel and bladder elimination in the toilet 

 N=5 

5/5 (100%) success Individual results: 

1 achieved consistent SI bowel & urine elimination at 3 wks; night soiling ended at 5 wks 1 achieved consistent SI bowel & urine elimination at 7 wks 2 achieved consistent SI bowel & urine elimination at 8 wks 1 achieved consistent ‘other’ initiated bowel elimination at 3 wks; urine at 8 wks with some SI 
D-74 

Table D-9. Outcomes and results of included studies (observational studies) (continued) 

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Mentally Handicapped Children

HolverstottCockrell 2002 

Azrin and Foxx Study takes place in 4 special education preschool classrooms in the same school district. Children attended 1⁄2 days. 

Prospective cohort 

Bowel and bladder successes and accidents 

Intervention acceptability Parent participation 

N=10; 9 completed (results at 6 wk) Classroom A: n=4 Trend of successes ↑ from 0.6 (0–1) to 

4.0 (0–8)/day, accidents ↓ from 2.2 (1–3) to 1.2 (0–3)/day 

Classroom B: n=2 Trend of successes remained stable 

(from 2.4 (1–4) to 4.3 (1–8)/day), accidents ↓ from 1.1 (0–3) to 0.7 (0–3)/day) 

Classroom C: n=2 Trend of successes remained stable 

(from 2.2 (1–3) to 3.2 (0–6)/day), accidents ↓ 1.2 (0–2) to 0.3 (0–2)/day) 

Classroom D: n=2 Trend of successes ↑ from 0.07 (0–1) to 

2.1 (0–4)/day, accidents ↓ from 1.5 (0–2) to 0.6 (0–2)/day 

Kimbrell 1967 

Operant conditioning v. conventional group 

Prospective cohort 

Vineland social maturity scale (VSMS) scores (social age, social quotient) Frequency of soiling 

Comparisons based on age Laundry use Change in social age and social maturation 

N=40 (results at 7 mos) VSMS scores (post test) Social age: OC: ↑ 0.42 v. CG: ↑ 0.10 

(p<0.05) 

Social quotient: OC ↑ 3.30 v. CG ↓ -0.15 

(p=ns) 

Toilet Training: OC ↑ 4.10 v. CG ↑ 0.30 

(p<0.001) No significant developmental gains No differences based on age Experimental group laundry use cut in 

half 
D-75 

Table D-9. Outcomes and results of included studies (observational studies and trials) (continued) 

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Mentally Handicapped Children

Lancioni 1980 

Azrin and Foxx (modified) 

Prospective cohort 

Independent toileting for urination 

Partiallyindependent, incomplete, and assisted toileting Urinary accidents Comparisons based on age, sex, sensory condition, and degree of self stimulation 

N=9 (results at 44 day followup) 9/9 (100%) achieved daytime 

independence and accidents ↓ to zero 

Partial and incomplete toileting not 

present 

1/9 (11%) continued to have occasional 

accidents 

Lancioni 1981 

Other: Intervention A: 25 potties in training setting v. Intervention B: no potties displayed Punishment used 

Prospective cohort 

Independent toileting Partiallyindependent, 

incomplete, and assisted toileting Urinary accidents 

N=5 (results at 60 day followup) Intervention A: 5/5 (100%) achieved 

independent toileting that continued at 60-day followup 

Mean successes: 6.8 actions/day 2 had no accidents 3 had the odd accident Intervention B was not effective: when 

switched to Intervention A with potties 

improvement began 

Lancioni 1981 

Other: Intervention A: 25 potties in training setting v. Intervention B: no potties displayed No punishment used 

Prospective cohort 

Independent toileting Partiallyindependent, 

incomplete, and assisted toileting Urinary accidents 

N=4 (results at 60 day followup) Intervention A: 4/4 (100%) achieved independent toileting that continued at 60-day followup Mean successes: 6.5 actions/day 1 accident occurred Intervention B was not effective: when switched to Intervention A with potties 

improvement began 
D-76 

Table D-9. Outcomes and results of included studies (observational studies) (continued) 

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Mentally Handicapped Children

Spencer 1973 

Operant conditioning Prospective 

cohort 

Index of bowel control N=38 

(results at 6 wk) Accidents ↓ by 17% Spontaneous toileting ↑ 9% Those who had greater initial bowel control did not improve, those totally incontinent showed considerable progress 

Smith 1977 Azrin and Foxx Retrospective 

cohort 

Wetting accidents/wk N=8 

(results at 10 wk) Wetting accidents: Younger, low social age (SA): 2/5 (40%) averaged 1 accident/wk Younger, high SA: 3/3 (100%) zero accidents 

Tierney 1973 

Operant conditioning v. control 

Controlled clinical trial 

Reduced incontinence Successful continence of urine and feces on 16-level scale where 16=independent 

Soiled linen Staff workload Number in nappies 

N=36 (results on 18 experimental patients at 30 day followup) OC: 14/18 (78%) improved and were removed from diapers 

7/18 (39%) achieved level 4 5/18 (28%) achieved level 3 2/18 (11%) achieved level 2 6/18 (33%) achieved nocturnal continence 4/18 (22%) showed no improvement 

Behavior relating to ‘sitting’ levels (5–8) 

more easily achieved than behavior relating dressing (9–12) and ‘going to the toilet’ (13–16) levels 

Control: showed minimal improvement 

Van Wagenen 1969 

Other: auditory signal followed by rapid forward moving series of training events 

Prospective cohort 

Criterion levels 1–6 where 6= self-initiated urination with no prompts 

 N=9 

(results at 19.5 hr to 22 days) 9/9 (100%) achieved level 6 
D-77 

Table D-10. Outcomes and results of included studies (trials) 

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Healthy children 

Candelora 1977 

Azrin and Foxx (TTLD) v. Dr. Spock 

RCT Mean bowel and 

bladder accidents/day 

Successes Wet or soiled mornings 

N=71 (results at 3 wk) Mean accidents/day/child: post training/ followup 

TTLD: 2.28/1.59 Dr. Spock: 3.02/2.50 

Mean successes /day/child: post training/ followup 

TTLD: 2.84/3.71 Dr. Spock: 1.3/2.09 

Mean wet mornings: post training/ followup 

TTLD: 73/63 Dr. Spock: 81/73 

Mean change from baseline in accidents (p=0.007) 

TTLD: 2.48 Dr. Spock: 1.37 

Mean change from baseline in successes (p=0.003) 

TTLD: 2.50 Dr. Spock: 1.12 

Mean difference in proportion of mornings children were wet (p=0.011) 

TTLD: 21% Dr. Spock: 6% 

Followup results for TTLD v. Dr. Spock 

were not significant 

24–35 mo. performed better than 18–23 mos 

CCT indicates controlled clinical trial; GTRP: group training regular potting; IIRP: intensive/individual regular potting; IITP: intensive/individual tiNS: not significant; OC: operant conditioning; RCT: randomized controlled trial; SCH: scheduled; STR: stool toileting refusal; TTLD: toilet trainin
D-78 

Table D-10. Outcomes and results of included studies (trials) (continued) 

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Healthy Children

Matson 1977 

Azrin and Foxx (book +

supervision) v. Azrin and Foxx (book only) 

RCT Number of accidents Emotional side 

effects 

N=10 (results at 10 wk) Book + supervision 

4/5 (80%) trained in 5 sessions (4–18 hr) 1/5 (20%) continued to have accidents 1/5 (20%) dropped out 

Book 

1/5 (20%) trained in 1.5 sessions (6 hr) 

1/5 (20%) partially trained in 5 sessions 

(20 hr) 

3/5 (60%) failures 3/10 (30%) of children trained also stopped nighttime wetting 

Taubman 2003 

Child-orientated approach with handbook, pretraining praise and no negative terminology v. childorientated approach with handbook 

RCT Stool toileting refusal 

(STR) 

Hiding while defecating Effect of age begun TT on duration Age at completion 

N=381 381/381 (100%) trained by 3.5 ± 0.5 yr During training: Incidence STR (p>0.10) 

Handbook plus: 26% Handbook: 23% 

Duration STR (p=0.03) 

Handbook plus: 5.1 ± 3.2 mo. Handbook: 7.3 ± 6.0 mos 

Incidence stool withholding (p>0.10) 

Handbook plus: 55% Handbook 2: 52% 

Incidence of hiding (p>0.10) 

Handbook plus: 70% Handbook 68% 

Age TT completed 

Handbook plus: 43 ± 6.5 mos Handbook: 40 ± 6.4 mos 
D-79 

Table D-10. Outcomes and results of included studies (trials) (continued)

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Mentally Handicapped Children

Edgar 1975 

Operant conditioning: relaxation-tension exercise regimen v. control 

RCT Frequency of accident 

Appropriate urination 

 N=20 

(results at 2 wks) Mean adjusted accident score/8hr (p<0.05) 

OC: 0.37 Control: 2.13 

Mean adjusted appropriate score/8hrs (p<0.05) 

OC: 8.1 Control: 3.9 

No change: 

OC: 2/10 (20%) Control: 8/10 (80%) 

Hundziak 1965 

Operant conditioning v. conventional v. control 

RCT Use of toilet for bowel 

and bladder elimination 

Transfer of behavior to other settings 

N=29 (results at 27 days) Median (IQ range) difference pre/post scores for defecation in toilet 

OC: 1 (0,3) (p=0.032) Conventional: 0 (0, 0.5) (p=NS) Control: 0 (0,1) (p=NS) 

Median (IQ range) difference pre/post scores for urination in toilet 

OC: 9 (2,10) (p=0.016) Conventional: 1 (-0.5, 2.5) (p=NS) Control: 1 (0,3) (p=0.032) 
D-80 

Table D-10. Outcomes and results of included studies (observational studies and trials) (continued) 

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

Mentally Handicapped Children 

Hyams 1992 

Intensive/individual regular potting (IIRP) v. group training regular potting (GTRP) v. Intensive/individual timed potting (IITP) 

RCT Decreased 

incontinence Increased independence 

Cost effectiveness Training time 

N=15;5 / group (results at end training/10 yr.followup)  Independent 

IIRP: 5/5 (100%) / 1/5 (20%) 

GTRP: 1/5 (20%) / 0 (0%) IITP: 4/5 (80%) / 0/5 (0%) 

No. of incontinent episodes/wk (% reduction from baseline) at 12 wk / 10 yr 

IIRP: 1 (99%) / 8 (88%) GTRP: 52 (39%) / 41 (52%) IITP: 23 (80%) / 30 (74%) 

Nurse training hours 

IIRP: 2330 GTRP: 1260 IITP: 2079 

Sadler 1977 

Azrin and Foxx v. scheduled (SCH) v. control 

RCT Urine accidents/day Staff preference 

Training time 

N=14 (results at 3 mos/4 mos) Mean wets/day 

AF: ↓ from 1 to 0.20 / 0.11 (p<0.01) SCH: ↓ from 0.95 to 0.77 / 0.57 Control: ↓ from 0.88 to 1.07 / 0.63 

Median time required in hours 

AF: 35 SCH: 5.3 Control: 2.9 
D-81 

Table D-10. Outcomes and results of included studies (observational studies and trials) (continued) 

AuthorYear Toilet Training Method(s) Study Design Primary Outcome Other Outcomes or Effect Modifiers Results 

 Physically Handicapped Children 

van Kuyk 2001 

Operant conditioning v. waiting list control 

CCT Bowel continence 

(Templeton, Wingspread, and constipation scores) Feces in the toilet Days without soiling Scale parental judgment incontinence 

Comparisons based on age 

N=27 (results at 9 mo.) Templeton score (p<0.001) 

OC: 1.3 ± 0.4 Waiting list: 2.2 ± 0.8 

Wingspread score (p<0.001) 

OC: 1.8 ± 0.6 Waiting list: 2.9 ± 1.1 

Constipation (p<0.05) 

OC: 1.1 ± 0.4 Waiting list: 1.7 ± 0.6 

Feces in the toilet (p<0.001) 

OC: 82.7% Waiting list: 40.2% 

Days without soiling (p<0.001) 

OC: 10.8 ± 3.0 Waiting list: 5.9 ± 5.4 

Parental judgment incontinence scale 

(p<0.05) 

OC: 12.4 ± 5.2 Waiting list: 16.4 ± 7.1 
E-82 

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E-84 

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F-106 

Appendix F: Technical Expert Panel and Peer Reviewers 

Technical Expert Panel 

Lola Baydala 

University of Alberta, Edmonton, AB 

Nathan Blum 

University of Pennsylvania, Philadelphia, PA 

Brenda Clark 

University of Alberta, Edmonton, AB 

Jennifer Shu 

Dartmouth Medical School, Hanover, NH 

Peer Reviewers 

Edward Christopherson 

Children's Mercy Specialty Center, Overland Park, KS 

Mark Feldman 

St. Joseph's Health Centre, Toronto, ON and The Hospital for Sick Children, Toronto, ON 

Lynne Haverkos 

National Institute of Child Health and Human Development, Rockville, MD 

Sally Longstaffe

University of Manitoba, Winnipeg, MN 

Virginia Moyer 

University of Texas, Houston, TX 

Leonard Rappaport 

Children’s Hospital Boston, Boston, MA 

Martin Stein 

University of California, San Diego, CA
G-107

Appendix G: Abbreviations 

AAP American Academy of Pediatrics 

ADHD attention deficit and hyperactivity disorder 

CCT controlled clinical trial 

CG conventional group 

CIC clean intermittent catheterization 

CPS Canadian Paediatric Society 

DSM IV-TR Diagnosis and Statistical Manual IV - Text Revised 

LUTS lower urinary tract symptoms 

MC mentally handicapped children 

NR not reported 

OC operant conditioning 

RCT randomized controlled trial 

RT regular toileting 

SA social age 

SCH scheduled 

SD standard deviation 

SI self-initiated 

SIE self-initiated elimination 

STR stool toileting refusal 

TEP technical expert panel 

TT toilet training 

UK United Kingdom 

VSMS Vineland Social Maturity Scale 
H-108 

Appendix H: Toilet Training Methods 

H-1. Child-Oriented Toilet Training Method 

H-2. Azrin and Foxx Toilet Training in Less Than a Day Method 

H-3. Early Elimination Toilet Training Method 

H-4. Dr. Spock’s Toilet Training Method 
H-109 

H-1. Child-Oriented Toilet Training Method 

Objective 

To prevent problems for a child in learning bowel and bladder control. Learning this control 

is a major developmental task and proper timing may enable a child to master the acts for him or 

herself. Training must proceed slowly to allow for periods of negativity that are common in this 

age group. If there is a breakdown at any time during training, parents are advised to stop and to 

reassure the child that he or she is not bad, but will learn when ready. 

Readiness 

• Child must be able to sit and walk. 

• Child must have some understanding of verbal commands. 

• Child displays psychological readiness: 

- has a desire to develop autonomy and self mastery, 

- feels secure with parent figures and has a desire to please them, and 

- has a wish to identify with and imitate important people in the child’s life. 

• Parents must ready themselves and deal with outside pressures and anxieties about toilet 

training, aiming for a relaxed, pressure-free approach. 

Method 

1. Around 18 months of age, introduce a potty chair as the child’s “own chair”. Allow the 

child to get familiar with it and verbally associate it with the parents’ toilet. 

2. Daily, have the child sit on the chair fully clothed when the parent uses the toilet. Parents 

may read or offer treats to the child while he or she sits but allow the child to leave at 

will. 

3. After 1 to 2 weeks cooperation, remove the child’s diaper and have him or her sit on the 

potty. Make no demands nor attempts to catch anything. 

4. When the child is comfortable with the potty and eliminates in his or her diaper, take the 

child to the potty, empty the diaper into it and explain that this is where bowel 

movements go. 

5. If the child appears to understand, take the child to the potty several times a day. 

6. As interest grows, remove diapers and pants for short periods, place potty nearby and 

encourage the child to use it at will and independently. Periodic reminders may be given. 

7. If child is progressing then put into training pants and instruct how to raise and lower 

them. 

After bowel control is obtained, boys can learn to urinate while standing by imitating other 

males. Nap and night training is left until later if it does not occur simultaneously with daytime 

control. 
H-110 

H-2. Azrin and Foxx Toilet Training in Less Than a Day Method 

Objective 

To teach child to toilet him/herself without reminders or assistance. 

Training begins at about 20 months of age. Assess bladder control, physical development and 

ability to follow instructions to see if child has developed sufficiently to acquire toilet training 

skills.A child is ready to be trained if he or she: 

• has bladder control, that is, the child urinates all at one time (not constant dribbling), 

stays dry for several hours and appears to know when he or she is about to urinate, 

e.g., facial expression or posture changes]; 

• is physically ready, i.e., picks up objects easily and walks without assistance; and 

• can follow 10 instructions: point to nose, eyes, mouth, hair, sit on a chair, stand up, 

walk with parent to another room, imitate simple tasks, fetch a particular object, and 

place one object inside another. 

Pre-training experiences 

• Teach the child to assist in own dressing and undressing, especially raising and 

lowering pants. 

• Allow the child to watch others toilet and explain the steps they are following. 

• Teach the toileting words to be used during training. 

• Teach the child to cooperate when given instructions; do not allow an instruction of 

which the child is capable to go unfulfilled; do not allow temper tantrums to 

discourage progress. 

Training supplies and setup 

• Conduct training in one room. 

• Eliminate or minimize all interruptions and distractions, e.g., toys. 

• Have a ready supply of child’s favorite drinks, snacks, and treats. 

• Use a potty chair designed so a child can easily remove the pot from the chair and 

replace it. 

• Have a doll that wets to demonstrate to the child the urination process. 

• Make up a list of the persons and characters (real or fictional) the child admires to use 

to praise the child and indicate how pleased they will be to hear of the child’s success. 

• Have at least eight pairs of training pants large enough for the child to easily lower 

and raise. 

• Have child wear a short T-shirt that will not interfere with lowering and raising 

training pants. Teach child to grasp pants in the middle of the back, palm facing 

backward, and mid-front for easier lowering and raising. 

Method 

Provide immediate, varied (juices, edibles, treats, hugs, etc.), positive reinforcement at every 

instance of correct toileting skill, e.g., approaching potty, grasping pants, sitting on potty, etc. Do 
H-111 

not reinforce non-toileting acts. Tell the child how happy [name significant other] will be that the 

child is learning to use the potty and to keep pants dry. 

Accidents: Verbal reprimand, omit reinforcement, have child change wet pants to dry ones by 

him or herself, conduct 10 rapid “positive practice” sessions as follows:

1. Use the doll that wets to imitate the processes of toileting and teach specific actions. 

Manually guide child through the proper actions, then let the child guide the doll through 

the process. 

2. When the doll urinates in the potty, teach the child to remove the pot, empty it into the 

toilet, flush and return the pot to the chair. Once this is learned, begin training child. 

3. Teach the child to check and identify dry pants from wet pants. Reward/praise dry pants. 

Perform checks every 3 to 5 minutes and keep track using a training reminder sheet. 

4. Give child as much to drink as desired to create a strong, frequent desire to toilet (at least 

8oz/hr). Use as a positive reinforcement. 

5. Instruct child to walk to the potty, lower pants, sit down quietly for several minutes, stand 

up, and raise pants. Watch to see if urination begins and praise/ reward immediately. 

6. After urination takes place, the have child wipe him or herself, and empty and replace pot 

as in 2 above. 

7. Increased number of trials: give prompted potty trials every 15 minutes in the beginning, 

decrease frequency as child acquires skill. 

8. Conduct “dry pants” checks every 5 minutes, have child do it as well. 

9. At first, have child sit on the potty about 10 minutes; after two to three successful 

urinations into the potty and much praise, the child will begin to understand and 

prompting and sit time can be reduced. 

10. Gradually change from directing child to “go potty” to asking child if he or she has to “go 

potty” to general questions such as “Where do you go potty?” and “Are your pants dry?”. 

Once child goes potty after a general question, only comment on dry pants. 

11. As child acquires skills and performs actions correctly, give approval only at the end of 

an action rather than during it. Eventually reduce to praising only dry pants. 

12. For next several days, do dry pants checks at meals, naps, bedtimes, etc., and praise each 

time pants are dry. If there is an accident, reprimand the child, have the child change by 

him or herself, and perform more practice sessions. No reminders to toilet are given. 
H-112 

H-3. Early Elimination Toilet Training Method 

Objective 

At one year old, child is expected to control elimination, walk, and verbalize simple needs. 

Method 

1. Bowel and bladder training begin simultaneously at 2 to 3 weeks of age. 

2. Initially, the mother assumes all responsibility by placing child in a special training 

position outside the house when she senses the child needs to eliminate (e.g., after 

feeding and waking). 

a. For voiding, mother sits with legs extended straight out, places the child in a 

sitting position between them facing away from her and supported by her body. 

She then makes a “shuus” sound so child learns to associate it with voiding. This 

is done many times over 24 hours. If successful, the child is rewarded with 

feeding, close contact or other pleasurable activity. 

The child is expected to gain competence in communicating his or her need to void and 

climb into the assumed position and urinate by 4 to 5 months. 

b. For bowel movements, mother sits on the floor with knees bent, infant facing her, 

supported by her lower legs. Child’s legs are placed over hers. The mother’s feet 

provide a kind of potty. No sound is made. If elimination occurs, the child is 

rewarded by pleasurable activity; if not, the child is returned matter-of-factly back 

to previous activity. 

During elimination, social activity carries on; elimination is not regarded as private or 

unclean. 

The mothers claim to learn to read infants’ movements, skin and muscle tension, and also 

distinguish a language of grimaces, grunts and cries to signal need. When specific pushes 

and shoves are detected while carrying a child on her back she may occasionally 

stimulate a sphincter reflex with a gentle pat to the rear. 

3. At 3 to 5 months, young girls 5 to 12 years old also learn the child’s signals and 

participate in further training by assuming elimination positions at appropriate times. 

Helpers are scolded or punished if they are not responsive or sensitive to infant’s needs. 

4. Occasional accidents are expected and handled casually; caregiver cleans up 

immediately. 

5. At one year, when infant begins walking, he or she is expected to eliminate away from 

the living area of the house. Accidents in the living area or courtyard first attract 

warnings and later physical punishment. 
H-113 

H-4. Dr. Spock’s Toilet Training Method 

Objective 

To train without force. Most children are ready between 2 and 2.5 years of age. If parents 

wait until a child is ready, the child will learn without being forced, and the process will be more 

relaxed and pleasant with fewer power struggles. The child must decide to gain control of bowel 

and bladder to be more grown-up. Parents must trust the child’s desire and be patient. Once 

training begins, parents must be consistent and convey the expectation that the child will toilet as 

older people do by praising and encouraging success, and avoiding criticism and anger in the 

event of accidents and refusal. 

Pre-training experiences 

Allow the child into the bathroom with other family members to learn about potting, but 

without the pressure to perform. Teach the child to wash his or her hands afterwards. Talk about 

what is happening so the child learns the words and also that toileting is a straight forward fact of 

life and not dirty, shameful, secret, or mysterious. Avoid commenting on how smelly or messy 

“poop” is so the child does not confuse criticism of evacuation with criticism of him or herself. 

Training supplies and set-up 

• small plastic child-size potty chair with the urine guard removed (boys and girls should 

learn to eliminate in the sitting position), 

• step stool and small bar of soap so the child can learn handwashing, and 

• books or toys near the potty to entertain the child. 

Method 

1. Get the child used to the potty chair. Have the child sit on the potty fully clothed for as 

long or short as child chooses. 

2. Once the child has accepted the seat, suggest the child use it for bowel movements the 

way the parents do. Let the child leave the seat whenever the child chooses so he or she 

does not associate potting with punishment or imprisonment. They ought to think of it as 

a voluntary act carried out with pride; do not urge or pressure the child if the child is 

unwilling. If movement occurs in diaper, show the child how to deposit it in the potty and 

say that is where he or she will do it soon, too. Do not empty the potty into the toilet and 

flush it while the child is watching. 

3. Once the child shows interest, take the child to the potty two to three times per day, 

especially if signals of impending elimination are detected. Praise the child for being dry 

for long periods just like “parent or favorite character.” Do not over-praise, as this age 

group does not like to be too compliant. When the child appears ready to be more 

independent, remove all lower clothing and place the potty nearby explaining to the child 

that he or she can use it whenever they need to by him or herself. The parent may give 

occasional reminders. Put the child back in diapers if the child resists or has an accident. 
H-114 

Children usually achieve bowel and bladder control at the same time. Once this control is 

obtained, switch the child to training pants. Do not scold the child for the occasional accident. 

Boys will learn to stand and pee sooner or later from imitation. 

Once control is achieved, teach proper wiping and handwashing. Teach the child to wipe 

from front to back; the parent may have to complete the job at first.