Iran J Pediatr. 2017 June; 27(3):e9656. doi: 10.5812/ijp.9656.

Published online 2017 June 12. Research Article

Toilet Training and Influencing Factors that Affect Initiation and

Duration of Training: A Cross Sectional Study
Jumana Hanna Albaramki,1,* Manar Awad Allawama,1 and Al-Motassem Fahme Yousef 2
1
Department of Pediatrics, School of Medicine, The University of Jordan, Amman, Jordan
2
Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman, Jordan
*
Corresponding author: Dr. Jumana Hanna Albaramki, Department of Pediatrics, Jordan University Hospital, P.O. Box: 1459, Amman 11821 Jordan. Tel: +96-2796693562, E-mail:
[email protected]

Received 2016 November 10; Revised 2017 February 01; Accepted 2017 April 07.

Abstract

Objectives: Aim of this study was to determine the pattern of toilet training (TT) in Jordan, the factors that are related to the initia-
tion age, duration and the methods of training used among different sociocultural groups.
Methods: Mothers of 1257 children attending pediatric clinics at Jordan University Hospital were directly interviewed.
Results: Mean initiation and completion ages were 22.5 ± 6.50 and 26.48 ± 9.37 months respectively. Families living in urban settle-
ment, first child in family, child-oriented approach, working mothers and mothers with higher level of education started training
later. The duration of toilet training was 5.80 ± 8.06 weeks and it was shorter in families who used the child-oriented approach.
Intensive method was used in 59.4%, child-oriented in 40.6%. Young mothers used more frequently the intensive method. Constipa-
tion and stool toilet refusal developed in 15.4% and 15.1% respectively and there was a significant association between constipation
and older age of starting toilet training.
Conclusions: Intensive method of training is more popular in our country and the initiation and completion age are earlier than
in other countries. The age of initiation may be increased as parents are better educated and a child-oriented approach becomes
more popular than the intensive approach.

Keywords: Toilet Training, Child-Oriented Approach, Intensive Method, Jordan,

1. Background this age increased to 21 to 36 months (5). At the end of the

90s, children were toilet trained 12 to 15 months later than
Toilet training is a challenging step for parents and children trained in the 50s (6). Most children now start
children that comprises many steps and requires the right training between 18 and 24 months. This may be attributed
integration of neurological, muscular, emotional and be- to the use of disposable diapers, many working parents
havioral elements. It is a developmental milestone in have less time available to train their children, and con-
child’s life where children discover their physical abilities sider their children young to be trained before 24 months
and react to external pressure (1). Failure of TT results in if the child -oriented method was used (7, 8).
physical and psychological consequences. Most of the studies on TT were done on western popula-
There are two methods of TT described in the last tions (6). Few were done in Middle East countries as Turkey
decade, a) the gradual child-oriented method designed (9, 10) and Iran (11). None were done in Jordan, so this study
by Brazelton (2) in 1962 where parents respond to the was conducted to determine the pattern of TT in Jordan,
child’s signals of toileting readiness and b) the structured the initiation age, the duration needed, the method used
endpoint parent oriented training method of Azrin-Foxx and problems encountered so that recommendations for
where caregivers actively teach toileting behavior (3). The proper methods can be obtained. The factors that might be
American Academy of Pediatrics 1999 recommends the related to the age of initiation and duration such as mater-
child-oriented way (1). There are many signs of readiness nal demographics and method of training were also evalu-
described in the literature that develop at different ages ated.
and indicate child’s readiness for TT (4), but most children
do not master readiness signs until the second birthday (5). 2. Methods
Many trials have been performed on the initiation age
and duration of TT and these showed an increasing trend A cross sectional study was carried out between June
toward initiating TT at an older age (6). During the 40s, par- and September 2014. A structured data sheet was used and
ents started TT before the age of 18 months, but nowadays data collected by direct interviews with mothers attending

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 Hanna Albaramki J et al.

outpatient pediatric clinics at Jordan University Hospital Table 1. Socio-Demographic Characteristics of the Patients
by a trained research assistant. A total of 1256 mothers were
interviewed. Characteristic No. (%)
The data included: current age; gender; season of TT; Child’s gender
age at starting the training; the duration needed; age
Female 600 (47.7)
of complete-day control and night-time control; ways of
Male 657(52.3)
training used as “rewarding”, “modeling”, “punishment”,
“telling stories” or regularly putting the child on the toi- Settlement

let; type of toilet (regular or potty) and presence of fam- Rural 136 (10.8)
ily support. Two methods of TT were assessed. The child- Urban 1121 (89.2)
oriented method was defined when the parents started TT
Mothers’ level of education
after the child showed certain readiness signs, and the in-
tensive method where parents started TT because they be- School 565 (44.9)

lieved that the age was appropriate without considering College 144 (11.5)

how much the child was ready. Other socio-demographical University 548 (43.6)
information included mother’s age, her level of education, Maternal status
number of siblings, maternal status (working or house-
Housewife 831 (66.1)
wife), settlement and person who gave TT. The problems
encountered during training as constipation and stool toi- Working mother 426 (33.9)

let refusal were also studied. Children with developmen-

tal delay and anomalies in the spinal cord or children with
chronic kidney disease and overactive bladder were ex- TT was given by parents in 87.4% of cases. Family sup-
cluded. Oral verbal consent was obtained from the moth- port by the presence of grandparents living with the chil-
ers who participated in the study after the approval of the dren was present in 27.1%. 70.2% of children had training
hospital’s local ethical committee. during the summer season. 354 (28.2%) of children were
first siblings. 24.1% had previous attempts of training.

2.1. Statistics
3.2. Initiation and Completion of Toilet Training
Data were collected, coded and entered into Statisti- The mean age of initiation of TT was 22.50 ± 6.50
cal Package for Social Science (SPSS version 16, SPSS Inc, (range 9 - 48) months. 181 (14.4%) of children had training
Chicago, IL, USA). Data were summarized as counts and per- under 18 months, 835 (66.4%) between 18 and 30 months
centages for categorical data and as means and standard and 241 (19.2%) of them over 30 months. The mean comple-
deviation (SD) for continuous data. Normality of data was tion age of daytime TT was 23.80 ± 6.70 months. Mean du-
assessed by Kolmogorov-Smirnov and Shapiro Wilk tests. ration of daytime TT was 5.80 ± 8.06 (range 1 - 72) weeks.
Homogeneity of variance was assessed by Levene’s test. Mean age of night time-control was 26.48 ± 9.37
Data of continuous nature among different groups months.
were compared by parametric inferential statistics (t- There was a statistically significant weak negative rela-
test and ANOVA) or non-parametric inferential statistics tionship between age of initiation and duration of train-
(Mann-Whitney U and Kruskal-Wallis) as applicable. Alter- ing (P < 0.0001, r = -0.128). The duration of toilet training
natively, data of categorical nature were compared among was statistically longer in families who started TT under 18
different groups by chi square or Fisher exact test as appro- months, compared to families who started TT between 18 -
priate. Correlation was assessed by Pearson or Spearman 30 months (7.6 ± 8.40 vs 5.50 ± 7.70 weeks, P < 0.007).
correlation tests. Statistical significance was considered as In univariate analysis, the factors that were signifi-
P < 0.05. cantly associated with later initiation and completion age
were presence of family support, first child, urban settle-
ment, university degree for the mother’s education, work-
3. Results
ing mother, child-oriented method for training, use of
punishment as a way of training (Table 2). There was no
3.1. Socio-Demographic Characteristics (Table 1)
correlation between mothers’ age, child’s gender, use of
Mean current age was 5.4 ± 1.9 years. 55.4% of children potty and initiation age. The only factor that affected sig-
were under 5 years old. Average age of mothers was 30.1 ± nificantly the duration of training was the child-oriented
12.3 years. Average number of siblings was 1.7 ± 1.6. method.

2 Iran J Pediatr. 2017; 27(3):e9656.

 Hanna Albaramki J et al.

Table 2. Factors Associated with Initiation and Completion and Duration of Toilet Traininga

Factors Associated with Training (n = Initiation Age, mo Completion Age, mo Duration of TT, w
1257)

Male (600) 22.8 ± 6.8 24.2 ± 7 6.1 ± 8.7

Gender Female (657) 22.4 ± 6.3 23.6 ± 6.4 5.6 ± 7.4

P Value 0.2 0.12 0.2

Yes (341) 24 ± 6.3 25.1 ± 6.5 5.3 ± 7.8

Family support No (916) 22.1 ± 6.6 23.5 ± 6.8 6 ± 8.2

P Value < 0.0001 < 0.0001 0.18

First child (354) 23.6 ± 6.4 24.9 ± 6.6 5.9 ± 8.7

Child rank Not first child (840) 22.1 ± 6.5 23.4 ± 6.7 5.8 ± 7.9

P Value < 0.0001 < 0.0001 0.9

Rural (136) 21.2 ± 5.9 22.6 ± 6.6 6.3 ± 8.2

Settlement Urban (1121) 22.8 ± 6.6 24.1 ± 6.7 5.8 ± 8.1

P Value 0.009 0.018 0.48

School (565) 21.4 ± 7 22.7 ± 7.1 6 ± 7.7

College (144) 22.8 ± 6.1 24.2 ± 6.8 6 ± 9.7

Level of education
University (548) 23.8 ± 5.9 25 ± 6 5.7 ± 7.9
b b
P Value < 0.0001 < 0.0001 0.8

No (831) 21.9 ± 6.8 23.3 ± 7 6.1 ± 8.1

Maternal occupation Yes (426) 23.9 ± 5.8 25 ± 6.1 5.4 ± 7.9

P Value < 0.0001 < 0.0001 0.14

Intensive (747) 22.2 ± 6.4 23.7 ± 6.6 6.5 ± 8.7

Reason for training Child oriented (510) 23.2 ± 6.7 24.2±6.9 4.9 ± 6.9

P Value 0.007 0.15 < 0.0001

Stories (199) 22.5 ± 6.5 23.6 ± 6.7 5.3 ± 7.9

Modeling (340) 22.5 ± 6.6 23.7 ± 6.6 5.7 ± 7.8

Rewarding (156) 23.7 ± 6.1 24.9 ± 6.5 5.4 ± 7.3

Method of training
Punishment (121) 24.7 ± 6.8 26.5 ± 7.1 7.5 ± 9

Regular taking toilet (441) 21.8 ± 6.4 23.1 ± 6.6b 5.9 ± 8.3

P Value < 0.0001c < 0.0001c 0.17

Yes (404) 22.6 ± 6.5 23.9 ± 6.6 5.8 ± 8

Use of potty No (853) 22.6 ± 6.5 23.9 ± 6.8 5.9 ± 8.1

P Value 0.98 0.96 0.96

a
Values are expressed mean ± SD.
b
Comparison between university level of education versus school
c
Comparison between punishment and other ways of training

3.3. Toilet Training Methods No correlation was found between children’s gender, liv-
Intensive method was used in 747 (59.4%) children, ing area, maternal education or occupation and method of
while child-oriented method was adopted in 510 (40.6%) training.
cases. Mothers who used intensive approach had a statis- Regular visits to toilet by observing the child and tak-
tically significant lower age than mothers who used child- ing him to toilet was the most commonly (35.1%) used way.
oriented method (29.4 ± 5.3 vs. 30.1 ± 18.2 years, P = 0.008). Modeling an older sibling or parent was seen in 27%, telling

Iran J Pediatr. 2017; 27(3):e9656. 3

 Hanna Albaramki J et al.

stories in 15.8%, rewarding as buying gifts or chocolate in working mothers, use of punishment as a way of training
12.4%, punishment methods such as scolding and spanking were associated with a later initiation and completion age.
in 9.6%. There was no correlation between mother age, gen- Koc et al. (9) also reported that higher maternal education,
der and ways of training. However mothers with more sib- working mothers, people living in cities start TT later than
lings used modeling more (P < 0.0001). others. Tahran et al. (10) also found that toilet training age
Potty training was used by 404 (32.1%) of cases and increased as maternal education level increased.
mean age of transfer to toilet seat was 16.3 ± 20.29 weeks. Intensive method was used more frequently in our
study and that is similar to a study in Iran, but different
3.4. Problems Encountered than in Belgium where 61.9% start training in response
Constipation was present in 15.4%, stool toilet refusal to signals from the child (8). No significant differences
in 15.1%. There was a significant association between pres- were found between the child-oriented and the intensive
ence of constipation and older age of starting TT (age of method of learning in terms of efficacy and adverse events
initiation 23.70 ± 7.3 vs 22.2 ± 6.6, P = 0.033). There was (15). In another review on TT, it was difficult to draw def-
no correlation between gender, duration of TT, or method inite conclusions on the superiority of one method over
adopted and development of constipation. Constipation the other (16). However, American academy of pediatrics
was more frequently in children of parents who used pun- guidelines recommend child-oriented approach (1).
ishment [OR (95%CI) = 3.2 (2 - 5), P = 0.006]. In our study problems as constipation occurred in
15.4%, stool toilet refusal in 15.4% and that is slightly lower
than described in other studies (13, 17).
4. Discussion
We found a correlation between presence of constipa-
tion and later age of starting training and Blum et al. (13)
Toilet training is an important but not well studied
found that the presence of constipation and stool toilet re-
subject in Jordan. This is the first study conducted on Jor-
fusal was associated with a later initiation age of TT. Other
danian children. The mean initiation age was 22.5 ± 6.5
studies have also found a correlation between stool toilet
months, which is similar to that in Turkish children (9,
refusal and late age of starting TT (13, 17).
10), but lower than other countries (8, 12) where the av-
erage age was 27.5 months (8). Possible explanations for The main limitation of the study was its cross sectional
this could be that the intensive method that is associated design as the collected data depended on the mother’s
with significantly earlier age of training was used more fre- statement about her child’s toilet training making the data
quently than the child-oriented method. Additionally, in subject to recall bias especially in children above 5 years.
our study 66.5% of mothers were housewives in compar- We recommend conducting a prospective cohort study in
ison to other studies (8) with a later initiation age where future and addressing other problems such as daytime
72.2% mothers were working mothers. Non-working moth- wetting.
ers have a significantly earlier initiation age than working
mothers. Completion age similar to initiation age in our
population was also earlier than that in Western societies 4.1. Conclusions
(13).
In our study girls started and finished training earlier
than boys as described in literature (5, 6). Girls show readi- In Jordan which is a developing country, intensive
ness signs earlier than boys (5) and they are influenced by method is more commonly used and both the initiation
socialization and desire to please parents, whereas boys de- and completion age of toilet training begin earlier than
pend on physiologic maturation (14), but that was not sta- those in developed countries.
tistically significant as also seen in other studies (9, 10). Du- Housewives, people living in rural areas, mothers with
ration of daytime TT in our study was significantly shorter a lower level of education, mothers who used the inten-
than in other studies; 5.8 ± 8.06 weeks vs 4.15 ± 4.48 sive method, start training earlier. Pediatricians and fam-
months (9) and there was a negative correlation between ily practitioners should provide proper counseling to the
age of initiation and duration implying that starting early mothers regarding the appropriate age and method of
may take longer time and that is also reported in other training. The use of the child-oriented method should be
studies (9, 12). encouraged for this will lead to a later initiation age and
In our study it was found that the presence of fam- shorter duration of toilet training. Other ways of training
ily support, first child rank, urban settlement, university as rewarding, and avoiding of punishment should also be
degree for the mother education, child oriented method, encouraged.

4 Iran J Pediatr. 2017; 27(3):e9656.

 Hanna Albaramki J et al.

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