Q: My child is almost 5 years old and isn’t yet toilet trained. Is this normal?
A: Although we often take it for granted, having control over urination and bowel movements involves a complicated set of physical skills and behaviors. These skills and behaviors develop gradually over the first few years of life, beginning in infancy. Every child is different, but more than 80 percent of children are completely toilet trained by age 5.
In babies, the bladder is very small and empties automatically through reflex action. Around the second year of life, children begin to develop the ability to sense when the bladder is full.
The ability to control the muscles that hold and release urine also develops slowly, usually between the second and third year of life. Daytime control often comes first and occurs between ages 3 and 4. This is usually followed by the ability to control nighttime wetting and the ability to interrupt and hold urine on demand.
All of this may happen at about the same time or early in the child’s life, making toilet training seem less complicated than it really is.
Because each child learns this process in stages and at different times, there may be nothing wrong with your child’s progress. Nevertheless, you are right to ask why this might not yet have happened. Several physical problems, such as the structure of the bladder or bowel, or muscle development can interfere with the development of toileting skills.
Your pediatrician can evaluate your child and refer him or her for tests to determine whether physical problems exist. If there are none, continued failure to develop control of the bladder or the bowel may indicate conditions such as enuresis or encopresis.
Enuresis (pronounced en-yur-ee’-sis), refers to frequent wetting every week for at least three months past the age of 5. “Encopresis” (pronounced en-co-pree’-sis) refers to occasional soiling accidents for at least three months past the age of 4. These conditions can only be ruled out after a physician has determined there are no physical abnormalities and that certain medicines aren’t causing the problem.
Toileting problems can run in families, although the causes of enuresis and encopresis are not well understood.
The most successful treatments for enuresis and encopresis commonly combine medical and behavioral components, such as certain medications and behavior training techniques. For example, the use of a bell-and-pad for enuresis, especially when done under the supervision of a health professional, is successful in up to 90 percent of the children for whom it is recommended. This approach can easily be combined with medication when indicated.
Effective treatment for encopresis tends to involve teaching parents and children how to increase the frequency of appropriate toileting behaviors while simultaneously keeping the bowels cleaned out through diet changes and/or medications.
Even if there is no reason to suspect a physical or clinical condition slowing your child’s progress, behavioral treatment can be effective in helping you and your child smooth the road toward success.
Deidre Donaldson, Ph.D., is Director of Pediatric Psychology Services at May Institute and Director of the Fernandes Center for Children & Families at Saint Anne’s Hospital in Fall River, Mass.
