Part 2

Diaper-Free Before 3: The Healthier Way to Toilet Train and Help Your Child Out of Diapers Sooner
by Jill Lekovic, M.D.

(Page 2 of 2)

Brazelton relied heavily on psychoanalytic theory to make the case that delaying toilet training was not only more convenient but also desirable from a developmental standpoint. He argued that children trained at a younger age were more prone to regression under pressure (or having accidents), and that this could be avoided by confronting this task at a more advanced stage of development. Writes Brazelton:

Parents and pediatricians are aware that the child's autonomous achievement in any developmental area frees him to progress to more advanced areas. Faulty mastery may leave him with a deficit that results in regression under stress. [Pathological symptoms such as constipation and enuresis] . . . usually reflect a fundamental psychological disturbance in the child's adjustment.

In short he felt that there was a connection between problems with potty training and the child's psychological well-being. This was not a new idea (I discuss a little history in Chapter 2), but Brazelton popularized it in a way that changed how everyone viewed toilet training. He took toilet training from being a natural part of a child's growth development and made it one with special psychological significance.

Myth #1: Toilet Training Has Special
Importance in Children's Psychological Development

Many experts have questioned the connection between toilet training and psychological disturbance in children over the years. Even one of the most popular and well-regarded pediatric reference textbooks, Nelson's, states: "There is little to indicate that the experiences involved in the toilet training of most children are of major psychological consequence." Of course being negative, humiliating, or punishing a child as a part of toilet training can damage her self-esteem and cause her to resist training. But these patterns reflect an underlying parental approach and attitude that impacts all areas of child development, not just toilet training. You should use the same measure of patience, flexibility, and love with toilet training that you do with all of parenting.

Myth #2: Babies Don't Know When They Are Voiding

Since Brazelton did his 1962 study, we have increased knowledge about the developing nervous system in babies and children. As part of his argument for later training, Brazelton referred to theories suggesting that babies are born with a simple reflex occurring at the level of the nerves in the spinal cord, which causes them to empty their bladder when it is full. The idea was that as the bladder fills, certain nerves sense it is full and those nerves directly set off a corresponding set of nerves that lead to the bladder being emptied. According to Brazelton's theory, voluntary control of voiding happens only when the brain matures enough to begin to control this simple reflex. This is clearly not the case, as the current medical evidence proves.

Today's experts have found that newborn babies already have brain-based control over voiding related to arousal. In fact PET scans have shown that specific areas of the brain become active in newborn babies before they empty their bladders. This means that the higher functions of the brain are getting some sensory input and then exerting control over the bladder in a way that is much more complex than a spinal reflex arc, even before birth. There are certain stages in the sleep cycle when the bladder does not empty. This fascinating area is wide open to research, but it is clear that Brazelton's assertions do not explain the system. The idea that there is a transition at some point in the child's development from reflex voiding to voluntary voiding, or any point when higher functions of the nervous system are not involved in voiding, has been completely discredited. So these facts shift the question from being "When does a baby's brain become involved in voiding?" to "When does a baby become consciously aware of these processes?"

This question of conscious awareness in babies presents itself in many forms. Parents often see their newborn baby smile, and many have asked me when babies know they are smiling or begin to smile on purpose. Usually I give a simplistic explanation that there are many expressions that occur spontaneously in babies, but they begin to recognize and smile at caregivers after about six weeks of age. The real answer is a little more complicated, but analogous to toilet training.

Facial expressions in babies can represent spontaneous events, or they can be responses to stimuli as simple as the discomfort of being cold or having gas or as complex as a feeling of comfort, fear, or even happiness. The differences among when your baby is unconsciously moving his facial muscles, when he is responding to his environment with reflexive grimaces and smiles, when he is imitating the expression of a caregiver, and when he is making the connection among seeing a caregiver, feeling happy, and deciding to smile about it are not measurable, at least with what is currently known about the cognitive development of humans. They occur over time and not at a single moment.

Bladder and bowel control are similar things in that there is a gap between what is possible in terms of conditioned behavior and when babies become aware of the process in the complex sense that involves anticipation, planning, and communication. This complex but completely apparent fact directly confronts the idea that the signs of readiness suggested by the Academy have real significance. As much as we wonder as parents what our babies think and feel when they smile, we accept that we really don't know, and we continue to smile and talk to them as they grow. The same should be true with potty training. There is no specific age when children become aware (or for that matter any age when we know that they are not aware) of their toileting needs. We should offer them cues to tune in to the signals from their bodies (see your baby flushed and grunting, take him to the potty, he feels relaxed sitting on the potty, and he has a bowel movement).

Myth #3: Early Training Causes More Frequent Accidents

This assertion has been completely disproven many times over since it was first made. In fact there is no evidence that children trained early have any increase in the amount or frequency of accidents throughout childhood. The opposite is true; children trained earlier have much more reliable and consistent control than older children who often make accidents one of their tools in their ongoing power struggle with caregivers. Most children go through episodes of increased frequency of accidents after they have been trained, and there does not seem to be any association between training method and these periods.

Brazelton advanced the theory that the ability to be voluntarily trained (and thus to be able to control accidents) correlated with development of certain parts of the central nervous system that control voluntary motor functions. He argued that this process occurs between twelve and eighteen months of age, and any training prior to that time would lead a child to regress when she entered later stages of development.

Copyright © 2006 by Jill Lekovic, M.D.

About the Author

Jill Lekovic, M.D., is a fellow of the American Academy of Pediatrics and faculty pediatrician at St. Joseph's Hospital and Medical Center in Phoenix, Arizona. She lives in Phoenix with her husband and three young children.