Monday, January 6, 2014

Is “He’ll do it when he’s ready” the worst cliché in potty training? (Why swimming salamanders should be left out of the bathroom)

Little Johnny’s mother is exasperated. She has tried everything to get her four year old to use the potty: rewarding, bribing, pleading, cajoling, drawing little targets on the bottom of the bowl, but the boy has made no progress. The first time Johnny’s parents sat him on the potty, he was 18 months old. When that failed, a well-meaning friend offered the advice, “Wait until he’s ready! You’ll mess him up, and he’ll never learn.” Now almost three years later, Johnny’s mom is wondering if she did this to him by not waiting long enough before that first attempt. Riddled with guilt, she turns to her peers for advice on how to train him before he embarrasses himself in kindergarten. “Don’t worry about it,” her friends all chime in once again. “He’ll do it when he’s ready.” Some even say “Stop trying so hard, they’ll all do it on their own eventually.”  And someone offers this encouraging anecdotal evidence: “Well, my little Petey just did it all own his own one day.” 

It sounds like reasonable advice. Everyone says it, including, in one form or another, potty training books. It absolves the parent of any guilt or need to take action. And it’s probably true that he’ll learn soon enough. But it’s not especially empowering advice for the mom who wants to help her child. And there’s something about it that just doesn’t sound right to me. I knew there was something erroneous about this way of thinking about development so I set out to explore the origins of this line, where it came from and the motives for perpetuating it. What I found was shocking.

People have different reasons for giving the ol’ “when they’re ready” line, and most of them have honest intentions. The problem is that without further clarification, the line suggests that potty training is innate; that it happens naturally without coaching, just like getting teeth or reaching puberty. Perhaps a child, while sleeping, grows the little piece of brain matter responsible for toileting. Any attempt at potty training before this milestone is sure to end in failure! To sit that child on a toilet is like making a tadpole climb a ladder.  So give up, parents, or your child will be destined toward self loathing the rest of his life...won’t he?

After pondering it for some time, it hit me. This is not a new idea. It is a very old one called maturational theory. Let me take you back to the year 1929.  A developmental psychologist named Arnold Gessell is fervently demonstrating to a baby girl how to climb up a set of stairs. The girl’s identical twin sister isn’t lucky enough get stair climbing lessons; she is the control group.  And wouldn’t you know it; both children learn to climb the stairs! Gessell eventually concludes that much of what humans do is innate, and it is futile to teach a child how to reach common milestones.   The age at which the children learn to climb, walk, or any number of tasks, he asserts, is a matter of genetic determinism. They will do it when their genes dictate they are ready. While there are some elements of truth to this, should this theory be applied to potty training? 

Swimming lessons are a waste of money for this Axolotl.

The problem with Gessell’s theory is that it was refuted by his contemporaries and nearly every successor since that time, including, in later clarifications, Gessell himself. A criticism of this study, for example, would point out that the twin without training was not kept in isolation of stairs or the people who climb them, including her own twin. Also Gessell’s sample groups were too small, and non diverse. According to one research paper, “Children were carefully sampled form the New Haven community to provide a homogenous, white, middle-class group of British or German Extraction from intact two-parent families. This sample, however, was meant to generalize to any infant...” (Thelen & Adolph). Furthermore, his hypotheses were extrapolated from results of one of his colleague’s observations on the inherent movement patterns of amblystoma, which is a fancy way of saying that he equated complex human performances to those of– literally – swimming salamanders. “Gessell clearly owes to Darwin his core assumption that the growth of mental life is continuous with and impelled by the same processes that drive all organic growth.” (Ibid) In other words, we are mere organisms. Put a baby in an oversized Petri dish with a potty, and as the processes unfold, she will eventually use it.  Though I write this hyperbolically, sadly, there have been cases of extreme neglect which disprove this assertion. In 1970, a 13 year old child named Genie was rescued from her parents after she had been locked in a room and tied to a potty chair her entire life. She was still not potty trained. (Watch the NOVA video.)
 Gessell passed away in 1961, before studies of certain feral children taught us much of what we know about the importance of environmental factors on human growth, even neuromuscular development. Even so, Gessell himself came to conclude a nurturing environment was important for the innate development to happen, thus creating a rather mind-boggling paradox. Gessell’s legacy to developmental psychology is that his work ignited the famous nature versus nurture debate, which raged for several decades before almost all psychologists came to the agreement that both nature and nurture were important for psychological– and to some extent physical–development. 

 Potty training, we now know, is one of those skills that requires both nature and nurture. While neuromuscular control of the bladder will happen on its own, society has adopted cultural expectations with regards to things like clothing and indoor plumbing that aren’t part of our evolutionary repertoire. There is no reason to believe the human brain will naturally direct a person toward a porcelain bowl like a cat to a pile of sand.  Proof positive: the city of Amsterdam issues over three thousand fines each year for public urination (Look!). Humans, it turns out, must be taught.  

Allow me deviate from my stance for a moment to acknowledge that the “nature” portion of potty training, according to some experts, is still worth consideration. Most sources will tell you that there is a degree of physical maturity that must be reached before potty training can begin. In general the experts are unclear and diverse on what exactly they mean by physical maturity.  Some maintain that children must be able to do everything from unbuttoning their pants to turning on the faucet. Advocates of Elimination Communication espouse the belief that children need only the skill of anticipating an imminent need to relieve oneself and expressing that need. The most commonly held middle ground is that children mainly need to be able to control their sphincter and bladder. In her charmingly titled book, “Pee, Poop, and Potty Training,” Alison MacKonochie says, “During the early months of life, your baby’s bladder only holds a very small amount of urine. As soon as the bladder is full, it automatically contracts and empties, forcing urine down the urethra. [...] As your baby grows, the capacity of the bladder will increase. By the time he has reached toddlerhood, voluntary control of the sphincter muscles will start to develop, and you will notice your child passes urine less frequently. This is just one of the signs that your child is ready to begin potty training.” 

So here we see that there is limited merit behind maturational theory, as it relates to elimination. A child whose bladder is emptying automatically is not going to have much success. But it’s rather ambiguous to say this happens by “toddlerhood.” When I attempted to find a more specific timeline for this bladder and bowel maturity, the numbers I found suggested anywhere from 3 to 24 months. Some suggested 15 months on average. While it certainly varies for individual children, on the whole, Western children are trained at an average age which is much higher than the average age of bladder and bowel maturation*. The age at which a North American child is potty trained today is almost double what it was at the beginning of the century, and also much higher than the rest of the world, excepting a few other industrialized countries**.  To suggest all these late trainers simply hadn’t reached an age of physical ability would be to suggest there is an epidemic of elimination muscle delay among developed countries. (Sources: *Sears, Robert R., Eleanor Maccoby, and Harry Levin (1957). Patterns of Child Rearing.  **

How do you know if your specific child has physical mastery of their bladder and bowels? A child who refuses to urinate until the diaper is put back on is a child who has physical readiness. A child who squats behind the couch every time she has a bowel movement is a child with bowel mastery. A young baby who pees selectively on his Daddy every time he is the one to remove his diaper might even have bladder control. In fact, there is no evidence even to suggest that bladder and bowel muscle control can’t be somewhat influenced by environmental factors in the same way other muscles can. Consider a tiny baby who flails her arms randomly, then learns to control her fingers when motivated by a toy. Elimination muscles are no different and can also be honed with motivation. Advocates of non-western toilet training methods, including Elimination Communication, have proven that infants are capable of being conditioned to control their bladders and bowels as early as two or three months. Any number of factors could provide this conditioning. This accounts for the diverse range of ages at which a child may reach this physical milestone.   

I am not suggesting that all parents should rush to train their newborn infants. Western culture is one that frowns upon things like crotchless pants and outdoor urination (it’s cold in Canada!), and there isn’t much evidence that suggests this extreme end of the spectrum has many long term advantages. Neuromuscular control– the harmony between the brain and bladder– is in fact innate, and will happen in time barring any developmental disorders. What I am suggesting is that by the time your child reaches the age of three or four, or whatever age the parents become very concerned, physical readiness is no longer the issue.

Psychological readiness, on the other hand, is a whole other question. And that, parents, is something you can have a hand in. But first, let’s go back to the prodigy, little Petey. Petey’s mom asserts that eventually he just went on his own without anyone training him. If potty training isn’t innate, how did that happen? The answer is that Petey is being conditioned every day. Presumably he’s living in a house with at least one toilet. He sees other people going into the bathroom. He hears them urinating, he may even see or smell them. He watches television: toilet paper commercials, potty training commercials; he reads books with pictures of personified animals inexplicably perched on human toilets. Maybe he goes to daycare or sees his peers use the toilet. He gets negative feedback when he defecates in his diaper and his mother wrinkles her nose, and when he eventually tries the toilet he receives some kind of praise or approval. Petey was still “trained” with a system, and that system was an eventual environmental conformity. It worked with his learning style, and the rate at which he adapted was acceptable for his parents. 

But this won’t work for everyone. It’s a slow process for most children. There are many reasons why a parent would seek out ways to hasten their child’s psychological readiness. Problems can occur if the process is taking too long. A child can become complacent with their diapering habits. Writes Behaviour Consultant Brenda Batts, “Very often, potty training is the last skill we think of implementing, and by the time we are confronted with potty training our children they have learned potty training behaviours that, because of the passage of time, have become ingrained in their repertoire of behaviours, making potty training a very difficult process” (Ready, Set, Potty, 2010).  

If this is the case, advising such a parent to wait it out may cause even more problems down the road. Secondly, an older child who is not yet potty trained may experience problems in daycare or school. While he may be able to quickly adapt to the toilet once he is in among peers who are using it, it is also possible that a child may be embarrassed or ostracised when he is the only one still in diapers. You cannot assume that peer pressure– or peer shaming– will result in increased motivation. Some programs will not even allow a child to enroll until they are toilet trained. While this is an unfortunate policy that I don’t wholly support, it’s a fact. 

Lastly, an extended period of diapering can be financially stressful on parents. Not everyone is able to use cloth diapers, and the cost of disposables is considerable. An extra year without disposables could pay for a semester of college. The slow-paced approach might not be advisable for parents with limited means.

There is no shortage of psychological obstacles which could prevent a child from responding to a potty training plan. Some children’s needs or learning styles are more complex than the scope of parents’ understanding. It’s possible that the system parents are using has not been individualized to their child’s specific needs. According to Butts, parents must “take into consideration a child’s unique learning modes, dislikes, and sensory issues, in order to develop and implement a program that is relevant and appealing to the child.” (Ready, Set, Potty). While the author is specifically referring to developmentally delayed children here, it is no less true of average children with issues causing delayed potty training. While I won’t go into all the ways of adapting a potty training program here, suffice to say that the child-directed pace will not be universally successful with all children. 

So this raises an important question. Why is “wait until they’re ready,” such a prevalent piece of advice? Even in potty training books, this statement is usually followed by, well, a whole entire book of ways to get help get your child psychologically ready, rather than sitting idly by and waiting. But the idea that there is nothing you can do to speed the process, and if you try you will damage your child, persists. 

I read at least dozen modern books on the topic and none of them actually suggest you should do nothing and your child will just come around. At most they suggests that breaks are advisable from time to time if your plan isn’t working, but abandoning the plan all together just to end the struggle and “wait and see,” is not something most experts recommend. 

Part of it can be traced back to Sigmund Freud, who had a lot of opinions about potty training and the potential trauma surrounding it. Freud was one of the original advocates for a child directed pace. But nowadays we understand that Freud’s theories are mainly directed against the horrific and often abusive toileting practices of the forties and fifties, and used out of context they become far reaching hyperbole.  Most authors acknowledge Freud’s contribution to developmental science but understand that applying his principles too rigorously amounts to alarmism. We now know that a common sense approach to toilet training is not going to cause personality defects or Oedipal relationships. So have we not tired of beating this dead horse, or is someone resurrecting it intentionally?  

Jennifer Margulis, journalist and author of “The Business of Baby,” makes a startling claim that it may be diaper companies themselves that are propagating this idea.  She writes that disposable diapers themselves are well known to cause delays in training, and that hospitals are enabling long term diaper habits by distributing free samples. But more alarmingly, Margulis alleges that “...Mommy bloggers were being paid by Kimberly-Clark to promote delayed potty training.” While it is difficult to find proof of this, it is worth bearing in mind that media sponsored by diaper companies may be subject to content that is supportive of long-haul potty training strategies. And since most parenting themed public sources are at least in part sponsored by Huggies or Pampers, their potential for control on the subject is significant. However, to be fair, the official advice put out by the Diaper Giants’ websites does contain a mixture of pro-training and pro-waiting advice. Pampers presents a wonderfully empathetic view on what potty training must be like for children, but they also subtly suggest that children must possess all the necessary skills from managing their own clothing to washing their own hands; skills many children still struggle with by elementary school. Must we teach such perfectionism? Letting children do what they can and offering assistance for everything else is a reasonable compromise. 

Huggies’ website offers the crucial recommendation that parents follow an individualized plan. But it offers few details on how to accomplish this. And they also have this to say: “If your child starts out fine, but then gets hopelessly stuck, no worries! It’s not unusual for the potty chair to go back into the closet for weeks, or even months. If your child loses interest, hold off for a few weeks and then try again. Toilet training is a developmental process. Children’s bodies and brains are developing all the time, and each new phase sets the foundation for those to come. No amount of teaching can make those developments happen before their time. You’ll have an easier, happy time of it if you wait until you’re sure your child is ready.” 

To me, this reeks of maturational theory. And in addition to resurrecting Gessell’s “no amount of teaching” adage, diaper companies are now attempting to convince the public that keeping your child in the right kind of diapers will somehow get him out of diapers sooner. All research suggests that ditching the diapers completely will give you a better result, and as that verdict became public knowledge, Diaper giants responded by creating something special for when your child is meant to get out of diapers: the Pull-up, which is another– and more expensive– diaper.  When educated parents first became aware that Pull-ups were statistically delaying the age of potty training, the diaper giants responded by encouraging the belief that it was because the diapers worked so well and were so absorbent and comfortable that their child had no idea they had urinated.  This may be true. If the diaper giants weren’t concerned with their bottom line, this should have resulted in a less absorbent or less comfortable diaper, which might have worked but no parent would buy it. Instead they came up with things like disappearing designs, which give your child an unnatural deterrent far removed from the feeling of wetness. 

Then some genius came up with Cool Alert, which is a little better, in theory, because being cool is at least something akin to being wet. But what exactly is Cool Alert? This information was not easy to come by- it has been removed from Huggies website. But at one point it read as follows, “When the child wets the pant, sorbitol crystals dissolve, which cools the urine in the patch. When the cool urine in the patch contacts the skin, the child feels the coolness. This cool feeling is similar to the change you feel when touching cool tap water. The pants remain cool for a few minutes. Sorbitol is a sugar-like material that occurs naturally in fruits such as apples, plums, cherries and pears. It is commonly used as a sweetener in gum and in low calorie foods. In cosmetics, sorbitol is frequently used as an emollient (skin softener).”

That sounds like a great product, with lots of positive associations! Who doesn’t like apples, plums, cherries, and gum? And it’s low calorie! And perhaps it would solve a problem if your child had rough genitals that needed softening.  The fact is, sorbitol is a sugar, and sugar should go nowhere near these orifices. The product reviews for Cool Alert are loaded with one-star warnings of rashes and infections. The package itself warns to discontinue use when a rash occurs, and where does that leave a child who is in the middle of a training plan based around Cool Alerts? Diaper companies do not have your child’s best interest in mind when reaching for your bottom dollar, and the ideas they circulate should be taken with caution.

Now don’t get me wrong. I’m not saying that all the information put out by diaper companies is meant to mislead you. Some of it is great, albeit incomplete, and some is just what certain people want to hear. What I’m suggesting is that the scales are weighted toward the long haul approach, in terms of readily available information. When given a choice between the findings of empirical scientific research, and opinions of those who adapt and redistribute those findings in order to better capitalize on keeping your children in diapers for as long as possible, it is the parents’ duty to find out about the many different approaches to potty training and select the one that best suits their child.

So let’s get back to Johnny’s Mom. If “wait until he’s ready,” is not a helpful piece of advice on its own, what is?  If you’re Petey’s mom, you might say, “Don’t stress needlessly. Many children in a nurturing environment eventually respond to societal expectations without too much coaxing. If this slow and subtle approach works best for you, it is a respectable choice.”  

But if the slow potty training is becoming an issue of concern for the parent and they are actually seeking advice on how to speed up the process, you might suggest, “Don’t take him out of diapers until he shows signs of readiness, but in the meantime you can look for ways to ready him that are conducive to his learning style and interests.”

But nobody talks like this. So perhaps the best advice might be “wait until you are ready.”  Do you have a plan? If your child is so young that you are not able to guess what approaches might be successful, you might need to wait until you are able to come up with an appropriate plan. But remember, if the plan fails, you won’t damage your child as long as you use a gentle approach. If your child resists, it’s still okay to wait until your child forgets about the failed strategy, and then come up with a new plan. You are not, as people might suggest, being an overly forceful parent if you introduce the potty and your child doesn’t take to it right away. In the next posts I discuss ways of individualizing plans and how to actually apply developmental psychology theories which hold more water than maturational theory.

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