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Potty training: How did it get so complicated?

(ran SP, PT, HT editions)

Ann Wright, of University Park, Md., woke up on a sweltering night in June at 3 a.m., her head spinning as she re-enacted the previous day's parenting trauma: She and her husband, Oliver, had told their 4-year-old daughter, Elizabeth, on Thursday night that it was time for her to stop using her pull-up training pants. For the next 18{ hours, the girl had withheld her urine, refusing to use the toilet.

"We had been talking to her for months about saying goodbye to the pull-ups, and she seemed ready," says Wright. "But on the day of the big break she refused to sit on the toilet. Two hours before she finally went, she was crying and constantly moving, clearly uncomfortable."

Eventually, the child wet herself.

Tossing in bed that night in the heat, Wright nudged her husband awake. "I can't go through with this," she told him. The next day the family went back to their previous routine: Every time Elizabeth needs to eliminate, she goes into the bathroom, takes off the necessary clothes, including her cotton underwear, and asks her parents to help her put on a diaper. If she empties her bladder, she carefully removes the diaper, gets dressed, washes her hands and walks out. If she poops, she asks for help.

Wright has decided to call a pediatric psychiatrist to review her daughter's history. "It's so weird," says Wright, leaning forward and grabbing her head in mock hysteria. "How did I screw this up so badly?"

Down the street in another house, Lesley Krauland, mother of two boys, has a different tale to tell.

She had potty trained her oldest son when he was around 2. "He was telling me when he had to go and sitting on the little potty chair," she says. "It was very successful."

But one day, he accidentally pooped in the tub. "I panicked," she said. "I yelled, "Oh no!' and swooped him out of the water and he cried, realizing, I think, he did not have control of his bowels. It was traumatic for him. I should have remained calmer."

Around the same time, Krauland had another child, and she believes that event, coupled with the tub accident, sent her older son into potty reversal. He'll be 4 in the fall, and he wears pull-ups. "He shows no interest whatsoever in the potty chair," she says. "I try not to be stressed about it, but of course it's really hard. Every mother I know who goes through this worries."

Worry is the last emotion you want to display when crossing the oh-so-fragile bridge of potty training.

"Toilet training is a very big change for the parents and child," says Miranda Schwartz, a pediatrician who has been practicing in Rockville, Md., for 15 years, "but it's not any more difficult than it used to be."

Nonetheless, those unlucky parents who are having trouble crossing this developmental bridge often find confusion and added anxiety when they start looking for help. Books (Everyone Poops, Once Upon a Potty, etc.), radio programs and TV talk shows offer conflicting advice: Train your kid by age 2 no matter what. Let your kid tell you when he's ready, even if he's 3. Offer sweets for potty success. Don't offer rewards. Use potty chairs. Use those little rubber doughnuts that fit on toilet seats. Sit in front of the toilet and coax your child. Don't coax your child.

While some parents consult doctors and other professionals for guidance, others compare techniques with fellow parents. They may find plenty of sympathy, but they also learn that one family's perfect solution is just another's frustrating failure.

Methods aside, parents' expectations have changed dramatically in little more than a generation. According to a 1957 Stanford study, 50 percent of parents began toilet training their children around nine months after birth, with 92 percent of all children trained by the time they reached 18 months old. Today, toilet training is occurring much later.

"There is no right age to toilet train a child," states an article in the June edition of Pediatrics, the journal of the American Academy of Pediatrics, but "In general, starting before age 2 is not recommended." Indeed, despite past practices, it is now common to find children ages 2, 3 and even 4 running around in diapers _ including the new size 6 diaper, which fits children 35 pounds and over. This change to later toilet training is causing problems for some children, stress for their families and conflicts between working parents and preschool workers who want the kids out of diapers.

In some circles, how and when you potty train says everything about what kind of parent you are.

"Toilet training has always been a significant milestone," according to Charles E. Schaefer, a child psychologist and author of Toilet Training Without Tears. "Unlike with learning to walk or to talk or to eat at the table, toilet training is the first real sign that you're a good parent or a bad parent _ however false that thinking may be."

"The public tends to make jokes about potty training," says Mark Stein, chairman of pediatric psychology and professor of pediatrics and psychiatry at George Washington University. "But it can be a very significant problem that disrupts the entire family."

Nathan Blume, a pediatrician at the University of Pennsylvania School of Medicine, agrees. "Clearly there is a lot of stress associated with toilet training today," he says, "not the least of which is coming from the preschools that require that the kids be trained. For many families, that's a very powerful stressor. Plus you have the pressure coming from friends and grandparents and other family members who are saying, "Why isn't this kid trained yet?' "

In the January 1997 edition of Pediatrics, Blume and Pennsylvania colleague Bruce Taubman reported on a study they conducted in suburban areas among middle- and upper-income families. The vast majority of the 482 children they followed began using the toilet before age 3. But 55 did not, and most of them experienced "stool toilet refusal," where the child refuses to defecate in the toilet or potty chair and instead empties his bowels elsewhere. The study concluded that a child who is not trained by age 3 "can be a source of family conflict and stress requiring the advice and support of the pediatrician."

"Parents are under such desperate pressure," says Adele Faber, a leader of the so-called child-centered approach to toilet training since the publication in 1980 of her book How to Talk So Kids Will Listen & Listen So Kids Will Talk. According to Faber, "We have a moral imperative to do something to help parents relax."

But how? And how did parents and children get in such a mess in the first place?

The experts seem polarized on just about every point but one: Potty training is more a problem today than in previous decades.

"I get about one call a week from frantic parents," says Stein. "A colleague of mine recently wrote a newspaper column in Missouri about toilet training, and he received more than 100 calls in one week." Stein cites two culprits for this growing concern: a lack of consistent child care in many households and a lack of what he calls "expert teachers" _ grandmothers, aunts, cousins and friends _ who can offer guidance on raising children.

"Today, both parents are often working, and child care is chaotic and changes frequently," Stein says. Schools and parents don't always jibe on their methods, which can confuse the child. And schools often insist on protection against accidents, which can set the child back.

Perhaps more important, families today are often isolated. Parents can't rely on an extended web of kinship for day-to-day support. As a substitute, many go to books for help and try myriad methods that end up confusing the child.

"It's so interesting that we base our parenting practices on these "schools of thought,' these books," says Wright. "But why are we so willing to read books and ignore the way we were raised, ignore our parents' methods? It's a pop psychology culture."

Judging from the people seeking Stein's advice, toilet training may be an issue more for an economic class than for our overall culture. While Stein says the people who come to him with these worries are generally from upper-income, highly educated families, he isn't sure whether that group is simply more likely than others to have insurance and more likely to consult a doctor for a problem that is not necessarily medical.

"I worked at a migrant preschool, and they didn't even have potty training," Stein says. "The kids just knew how to do it, probably from living so closely with other family members."

The children he sees fit a certain profile, too. "They are usually very bright, very self-directed children involved in a lot of structured activities whose parents are also high achievers," says Stein. "You know, a red flag really goes up when a parent comes to me and says their kid doesn't have time to learn to use the potty. The issue is very culture-specific, a symptom of our social condition."

Aside from these social factors, a child's toilet training progress can be affected by sudden change or mild trauma, such as moving, the birth of a sibling or a change in day care.

Some children suffer from physiological problems that make it hard for them to give up their diapers, and Stein suggests that parents rule these out first by seeing a doctor.

Stein looks for genetic abnormalities or nutritional problems such as too much dairy or a lack of fiber. "It could be something dietary or anatomical that's causing constipation or pain," he says. Next, he reviews the family's schedule and living patterns.

"You have to look at where the training failed," he says. "Was the toilet too tall? Was the stepping stool unstable? We look for lack of consistency from a babysitter or perhaps too much attention associated with accidents. Sometimes, it's simply a matter of working with the family's schedule, maybe sitting the kid on the pot 10 minutes after breakfast and 10 minutes after dinner."

In extreme cases, "children are going six and seven days without a bowel movement," says Stein. This can cause distended bowels, lack of energy, anal fissures and poor absorption of vitamins and nutrients. The constipation and fissures create pain, further traumatizing the child. "It turns into a chronic problem," says Stein. "The fears and phobias will run the kid's life."

Many parents successfully train their children, of course, without consulting any professionals.

Marietta Lorenz, a south Texas mother of five, has never read a parenting book. She trained her first four kids to use the potty by roughly age 2; the fifth will face the same regime in another year or so. Her approach is to take the kids' diapers off and ask them every hour if they need to use the potty. Some of her kids used the potty chair. Some used the regular toilet. Nakedness, at any rate, seemed to be key. And in the belief that kids mimic their elders, her family also uses what she calls "an open-door policy" _ as often as possible, everyone uses the toilet with the bathroom door open.

Sara Revers, an Alexandria, Va., mother of two, insists that toilet training is no more stressful than any other developmental stage. "It's not about dominance or control," says Revers, who hasn't read many parenting books but has received input on toilet training from her older sister, also a mother. "You can't force biology."

Some parents seem content to wait until their children are ready, no matter how long it takes.

"It seems kids are getting trained later," says Tom Hickey, a pediatrician in Columbia, Md. "But parents don't seem necessarily more stressed about it. A lot of parents, it seems, are getting information that it's not something to be stressed about if your child is not trained by age 3, so parents are not overly concerned about it."

One of Hickey's patients is a 4-year-old girl who is still not potty trained. "I explained to the mother that that's a little out of the spectrum of what is considered normal, and I asked the mother if she wanted names of psychiatrists or psychologists who specialize in this, but she said it's fine, she's not worried about it."

Hickey is currently training his own daughter, age 4, who, like Elizabeth Wright, wears cotton panties but puts on a diaper to poop or pee. "I recommend to parents that they not push it," he says. "I get some parents who want to start at around 14 months, but I don't think most children are neurologically ready at that point. The most important thing is to use non-threatening, non-punishing tactics."