ORIGINAL

ARTICLES

BELIEFS ABOUT THE APPROPRIATE AGE FOR INITIATING TOILET TRAINING:

ARE THERE RACIAL AND SOCIOECONOMIC DIFFERENCES?

IVOR B. HORN, MD, MPH, RUTH BRENNER, MD, MPH, MALLA RAO, DRPH, MENGG, AND TINA L. CHENG, MD, MPH

Objective To examine racial and socioeconomic differences in parental beliefs about the appropriate age at which to initiate
toilet training.
Study design A cross-sectional survey of 779 parents visiting child health providers in 3 clinical sites in Washington, DC and
the surrounding metropolitan area completed a self-report survey. The main outcome variable was parental beliefs about the
appropriate age at which to initiate toilet training. Using multiple linear regression, differences in beliefs were assessed in
relation to race, family income, parental education, parental age, and age of the oldest and youngest children.
Results Among respondents, parents felt that the average age at which toilet training should be initiated was 20.6 months
(7.6 months), with a range of 6 to 48 months. Caucasian parents believed that toilet training should be initiated at a
significantly later age (25.4 months) compared with both African-American parents (18.2 months) and parents of other races
(19.4 months). In the multiple regression model, factors predicting belief in when to initiate toilet training were Caucasian race
and higher income.
Conclusions Race and income were independent predictors of belief in age at which to initiate toilet training. More research
is needed to determine what factors contribute to toilet training practices in diverse populations. (J Pediatr 2006;149:165-8)

oilet training is a significant milestone for parents of toddlers and young children regardless of race/ethnicity, family

T income, or parental education level. Parents often seek advice about toilet training from family and friends. Thus, this
advice is typically solicited from persons of similar racial, cultural, and socioeco-
nomic background as the parents. However, when toilet training challenges (eg, toileting
refusal, constipation, encopresis) arise, parents often turn to their childs pediatrician for
guidance.
A 1962 article by Brazelton focused on toilet training using a more child-oriented
approach.1 Initiation of toilet training begins when a child shows signs that he or she is See editorial, p 151
developmentally ready to begin this process. A recent study found that 72% of pediatri-
From the Department of General Pediat-
cians surveyed recommended a gradual, passive, more child-oriented approach to toilet
2 rics and Adolescent Medicine, Childrens
training as suggested by Brazelton. Despite this approachs popularity, however, Brazel- National Medical Center, Washington, DC;
tons study provided no empirical outcome data to support it. In the 1970s, Azrin and Center for Health Services and Community
Research, Childrens Research Institute,
Foxx added a structured-behavioral method to this approach that delineated steps toward Washington, DC; Department of Pediat-
3 4,5
independent toileting. This study was replicated in other populations; however, less rics, George Washington University School
of Medicine, Washington, DC; National In-
than 1/3 of pediatricians surveyed endorsed the use of a more intensive toilet training stitutes of Child Health and Human Devel-
2
approach. opment, National Institutes of Health, De-
Pediatricians often come from different racial and cultural backgrounds than their partment of Health and Human Services,
Bethesda, MD; Division of General Pediat-
patients and may endorse different approaches to toilet training.6 These differing beliefs rics and Adolescent Medicine, Johns Hop-
about toilet training between parents and child health professionals may hinder the kins University, Baltimore, MD.
effectiveness of guidance.7 Submitted for publication Aug 18, 2005;
last revision received Dec 22, 2005; ac-
On average, children are developmentally ready to begin toilet training at age 18 cepted Mar 1, 2006.
months and achieve complete training by age 2 to 3 years. However, the age of initiation Reprint requests: Ivor Braden Horn, MD,
of toilet training has progressively increased in the United States from under 18 months MPH, Childrens Health Center at Good
Hope Road, Childrens National Medical
in the late 1940s to 21 to 36 months today.8-10 It has been suggested that the convenience Center, 2501 Good Hope Road SE, Wash-
of disposable diapers and underwear (pull-ups) may be contributing to this trend of ington, DC 20010. E-mail: ihorn@cnmc.org.
0022-3476/$ - see front matter
Copyright 2006 Mosby Inc. All rights
reserved.
AA African American SES Socioeconomic status
10.1016/j.jpeds.2006.03.004

165
delayed training.11,12 If this is a plausible explanation, then
those less likely to afford the expense of prolonged diaper use
may be more likely to initiate toilet training at an earlier age.
However, it is unclear whether there are differences in beliefs
about the initiation of toilet training based on socioeconomic
status (SES). There is some evidence that African-American
(AA) children are toilet trained at an earlier age and that their
parents believe in earlier initiation of training.13 Previous
studies on toilet training have been limited to comparisons of
predominantly Caucasian children with highly educated, sub-
urban parents with lower-SES AA families.13 Consequently,
suggestions based on previous research that AA parents be-
lieve in earlier initiation of toilet training compared with
Caucasians are confounded by SES. Consequently, the goal of
this study is to examine differences in parental beliefs about
the appropriate age at which to initiate toilet training as well
as predictors of differences in beliefs among a racially and
economically diverse population.
METHODS
The study was conducted at 3 clinical sites in Wash-
ington, DC and the surrounding metropolitan area: an urban
childrens hospital primary care center, an urban managed
care clinic, and a suburban private practice. The work de-
scribed in this article was part of a larger study whose primary
purpose was to examine community norms on multiple par-
enting beliefs and practices.14,15 Between January 1999 and
July 2000, a convenience sample of all English-speaking par-
ents/guardians visiting child health providers at the 3 clinical
sites were approached, given a brief explanation of the study,
and asked to participate in a 10-minute anonymous self-
report questionnaire that included questions on child-rearing
attitudes, beliefs, and practices, as well as sociodemographic
information.
Research assistants approached families in the waiting
rooms of the 3 clinical settings and invited them to participate
in the survey. A brief written survey was handed to the adult
who brought the child to the clinical visit. Only 1 survey was
provided, even if both parents were present. A research assis-
tant was available to read the survey questions if a respondent
requested assistance. This study was approved by the Institu-
tional Review Board of Childrens National Medical Center.
The primary outcome variable for the current analysis
was parental beliefs about the age at which toilet training
should be initiated. (Respondents were not given a specific
definition of toilet training.) Specifically, respondents were
asked: At what age should a parent start toilet training a
child? Participants recorded responses directly on the ques-
tionnaire by circling the age on a horizontal line that had ages
marked every 6 months beginning at 6 months and continu-
ing through 5 years. The survey was pretested before admin-
istration, including interviews with parents on their interpre-
tation of the questions and a pilot survey (n 65).
Our primary interest was to determine whether beliefs
about initiation of toilet training were associated with race.
Response categories on the data form for race included Black
166 Horn et al
or African-American, Caucasian, Asian or Pacific Is-
lander, American Indian or Alaskan Native, and other. In
adjusted analyses, the latter 3 categories were included in a
single other category, because together they accounted for
only 8.1% of respondents. Other variables examined as po-
tential confounders included parental religiosity (as measured
by parents response to the Likert-scaled question: How
important is religion to you?), educational level, ethnicity,
marital status, age, and gender; practice setting; number of
children in the family; household income; and ages of young-
est and oldest children.
Statistical analysis was performed using the STATA
version 8.0 (STATA, College Station, TX) software package.
In unadjusted analyses, intergroup comparisons for categorical
variables were performed using the 2 statistic. For normally
distributed continuous variables, analysis of variance was used
to compare group means. Variables that were statistically
associated (P .05) with both the outcome of interest (ie,
mean age at which toilet training should be initiated) and race
were included in the multiple linear regression model. A P
value .05 was considered statistically significant and was
appraised in a 2-tailed manner.
RESULTS
A total of 1004 eligible participants were approached
for the study, and 922 surveys were completed, for a partici-
pation rate of 92%. Of the 922 respondents, 833 listed them-
selves as the parent of the child and provided information on
race; of these 833, 779 had information on toilet training
because this question was added later in the study. These 779
respondents are the focus of this analysis.
Characteristics of the respondents, their children, and
their households are given in Table I. The respondents were
primarily female (85.3%). Race was most often reported as
AA (59.4%) or Caucasian (32.4%); 30% of respondents had
12 years of education, and 40.6% were college graduates.
Approximately 1/3 of respondents reported a family income
of $25,000, and 44.7% reported an income $50,000.
Parents who did not complete information on toilet training
did not differ from the parents included in the analysis on any
of the respondent or family characteristics examined.
The average age that parents felt that toilet training
should be initiated was 20.6 months (7.6 months), with a
range of 6 to 48 months. Caucasian parents reported a belief
that toilet training should be initiated at a later age than AA
or other parents (25.4 months vs 18.2 and 19.4 months,
respectively; P .0001); however, there was no significant
difference in beliefs between AA and other parents (P
.1789). Other factors associated with parental beliefs regard-
ing the age at which toilet training should be initiated in-
cluded practice site and parental income, education, age, and
belief in the importance of religion (Table II). Variables not
significantly associated with beliefs regarding toilet training
included age of the youngest child in the family, age of the
oldest child in the family, and number of children in the
family. Each of the respondent factors associated with beliefs
The Journal of Pediatrics August 2006
Table I. Characteristics of study participants Table II. Mean age of beliefs regarding initiation of
n % toilet training (unadjusted)
Mean age of
Respondent characteristics
initiation
Race (n 779)
(SD), years P value
Black or African American 462 59.4
Caucasian 252 32.4 Race (n 779)
Asian or Pacific Islander 20 2.6 African American 1.52 (.57)
American Indian or Alaska Native 4 .5 Caucasian 2.12 (.55) .0001
Other 40 5.1 Other 1.62 (.58)
Hispanic ethnicity (n 739) 35 4.8 Annual family income (n 716)
Female gender (n 773) 659 85.3 $50,000 1.52 (.56) .0001
Mean age of parent (n 765) 34.0 $50,000 1.98 (.58)
Education (n 776) Education (n 776)
Less than high school 54 7.0 High school graduate or less 1.49 (.57)
Completed high school 183 23.8 Some college 1.59 (.60) .0001
Some college 224 28.9 College graduate or later 1.98 (.59)
Completed college 128 16.5 Religious importance (n 741)
Postgraduate 187 24.1 Very important 1.64 (.62)
Marital status (n 490) Fairly important 1.83 (.64) .0001
Single 117 28.9 Fairly unimportant 1.93 (.49)
Married 330 67.3 Not important 1.83 (.64)
Separated/divorced/other 43 8.8
Religious importance (n 741)
Very important 453 61.1 age, AA parents believed in initiating toilet training at age 18
Fairly important 195 26.3 months, compared with 25 months for Caucasian parents.
Fairly unimportant 49 6.6 These differences persisted even after adjustment for con-
Not important 44 5.9
founders, indicating that the effect of race is likely indepen-
Family characteristics
dent of other important factors, such as income. This research
Annual household income (n 716)
$25,000 227 31.7 suggests that beliefs about toilet training may be culturally
$25,000 to 49,999 169 23.6 influenced independent of childrens biological readiness.
$50,000 320 44.7 In a 1970s study of mothers with first-born children age
Mean number of children in family (n 2.16 6 to 10 months, 33 (50%) of the 66 respondents reported that
778) they planned to initiate toilet training at age 16 months or
Mean age of youngest child in years (n 4.49 sooner.16 In contrast, a number of studies have examined the
768) actual age of initiation. For example, a study of 318 predom-
Mean age of oldest child in years (n 8.92 inately Caucasian infants in Pennsylvania reported a mean age
768) of initiation of toilet training of 20.9 months (2.6 months)
and a mean age of initiation of intensive toilet training of 28.7
months (5.6 months).17 These findings are consistent with
regarding initiation of toilet training was also significantly the age of 25 months reported by Caucasian parents in our
associated with race and thus was included as a potential study. It is unclear whether the reports of later initiation of
confounder in the multiple regression analysis. (Note that toilet training in the United States8,10,17 are real or are a
practice site was excluded from the final model because it was reflection of the predominantly Caucasian, educated, subur-
highly correlated with race.) ban populations studied. We are unaware of any recent stud-
In the adjusted model, only race and income were ies directly assessing the age of initiation or completion of
significantly associated with the outcome of interest. After toilet training among AA children. Schum et al13 used sta-
adjusting for confounders, on average Caucasians believed in tistical modeling to predict the age of initiation and comple-
initiating toilet training 4.2 months later than AAs (P tion of toilet training based on a 1995-1996 survey of 496
.001). Although income was also significant in the adjusted parents of children age 15 to 40 months. Their study esti-
model (P .03), the effect size was modest. Respondents mated the age at which 50% of children started toilet training
with an annual family income $50,000 reported a belief in as 21 months for AA children, versus 29.5 months for Cau-
initiating toilet training 1.3 months later than respondents casian children.13 Some investigators have attributed the ob-
with an annual family income $50,000. served racial differences in age of initiation of toilet training to
earlier attainment of motor skills by AA children.13,18,19
DISCUSSION However, previous research on toilet training outside the
This study found racial differences in beliefs about the United States found initiation of toilet training as early as age
appropriate age at which to initiate toilet training. On aver- 2 to 3 weeks and completion by age 1 year.20 Our study

Beliefs About The Appropriate Age For Initiating Toilet Training:

Are There Racial And Socioeconomic Differences? 167
suggests that AA children are toilet trained at an earlier age
because they begin this process sooner, based on their parents
beliefs. Consistent with this, in the survey by Schum et al,13
50% of AA parents agreed with the statement that it is
important that a child be toilet trained by the age of 2,
compared with only 4% of Caucasian parents.
Interestingly, in our study family income was also in-
dependently associated with beliefs regarding the age at which
to initiate toilet training, with upper-income parents (
$50,000 per year) reporting that toilet training should begin at
about age 2 years, compared with age 18 months for lower-
income parents. Although this effect size was reduced in
adjusted analyses (to a 1.3-month difference), the association
was still statistically significant. Our study did not explore
why parents believed that a particular age was best to begin
toilet training; however, it is possible that the cost of dispos-
able diapers and underwear (pull-ups) may play a role in
determining when parents initiate toilet training. If parents
cannot afford the cost of disposable diapers and underwear,
they are more likely to be motivated to initiate toilet training
at a younger age. Parents might also initiate toilet training at
a younger age in response to the reduced cost and expanded
options for child care that are available for toilet-trained
children. We found independent associations between both
income and race and beliefs regarding the proper age for
initiating toilet training, indicating that economic and cul-
tural factors must be considered when examining influences
on child-rearing beliefs and practices.
This study has several limitations. First, the study did
not provide parents with a definition of initiation of toilet
training (although in pretesting, there seemed to be little
ambiguity). Second, data from this study may not be gener-
alizable to other populations. Demographics of the study
participants do not represent all populations in the geographic
region or metropolitan area. Limiting the study to English-
speaking participants likely biased against recent immigrants,
potentially influencing the extrapolation of results to this
population. Nonetheless, the study population demographics
were similar to those of the participating practice populations.
Participants were instructed that their health care providers
would not be informed of their responses to the survey.
However, social desirability may have biased responses to
reflect the influence of the providers on parents practices.
Parents want information from their providers on toilet
training, particularly when challenges (eg, delayed toilet train-
ing, constipation, encopresis) arise.21 To be effective, advice
given by pediatricians must consider parental beliefs about
toilet training, along with the economic and sociocultural
factors that may impact on those beliefs. The current trend of
pediatricians recommending a gradual, passive approach to
toilet training may not be relevant to the economic or cultural
needs of a given family. Research on toilet training and other
child-rearing practices must include racially, ethnically, and
economically diverse populations and should include the
168 Horn et al
study of factors that contribute to parents beliefs and behavior
as well as child outcomes. When studying health behavior,
differences based on race and socioeconomic factors must be
taken into consideration. By understanding what motivates
parents from all racial/ethnic and economic backgrounds, and
what (if any) effect these motivations have on child outcomes,
providers will be able to more effectively counsel parents on
toilet training and other important parenting topics.
REFERENCES
1. Brazelton TB. A child-oriented approach to toilet training. Pediatrics
1962;29:121-8.
2. Polaha J, Warzak WJ, Dittmer-McMahon K. Toilet training in pri-
mary care: current practice and recommendations from behavioral pediatrics.
J Dev Behav Pediatr 2002;23:424-9.
3. Azrin N, Foxx R. Toilet training in less than a day. New York: Simon
& Schuster; 1974.
4. Foxx R, Azrin N. Toilet training the retarded. Champaign, IL:
Research Press; 1973.
5. Foxx RM, Azrin NH. Dry pants: a rapid method of toilet training
children. Behav Res Ther 1973;11:435-42.
6. Ritblatt S, Obegi A, Hammons B, Ganger T, Ganger B. Parents and
child care professionals toilet training attitudes and practices: a comparative
analysis. J Res Child Educ 2003;17:133-46.
7. Thienemann M. Toilet training, enuresis, and encopresis. In: Steiner
H, editor. Treating preschool children. San Francisco: Jossey-Bass; 1997.
8. Bakker E, Wyndaele JJ. Changes in the toilet training of children
during the last 60 years: the cause of an increase in lower urinary tract
dysfunction? BJU Int 2000;86:248-52.
9. Martin JA, King DR, Maccoby EE, Jacklin CN. Secular trends and
individual differences in toilet-training progress. J Pediatr Psychol
1984;9:457-67.
10. Schum TR, Kolb TM, McAuliffe TL, Simms MD, Underhill RL,
Lewis M. Sequential acquisition of toilet-training skills: a descriptive study of
gender and age differences in normal children. Pediatrics 2002;109:e48.
11. Schmitt B. Toilet training: getting it right the first time. Contemp
Pediatr 2004;21:105-16.
12. Stadtler AC, Gorski PA, Brazelton TB. Toilet training methods,
clinical interventions, and recommendations. Pediatrics 1999;103:1359-61.
13. Schum TR, McAuliffe TL, Simms MD, Walter JA, Lewis M, Pupp R.
Factors associated with toilet training in the 1990s. Ambul Pediatr
2001;1:79-86.
14. Cheng TL, Brenner RA, Wright JL, Sachs HC, Moyer P, Rao M.
Community norms on toy guns. Pediatrics 2003;111:75-9.
15. Cheng TL, Brenner RA, Wright JL, Sachs HC, Moyer P, Rao MR.
Childrens violent television viewing: are parents monitoring? Pediatrics
2004;114:94-9.
16. Stehbens JA, Silber DL. Parental expectations in toilet training. Pedi-
atrics 1971;48:451-4.
17. Blum NJ, Taubman B, Nemeth N. Relationship between age at initi-
ation of toilet training and duration of training: a prospective study. Pediat-
rics 2003;111:810-4.
18. Frankenburg WK, Dick NP, Carland J. Development of preschool-
aged children of different social and ethnic groups: implications for devel-
opmental screening. J Pediatr 1975;87:125-32.
19. Oppel WC, Harper PA, Rider RV. The age of attaining bladder
control. Pediatrics 1968;42:614-26.
20. deVries MW, deVries MR. Cultural relativity of toilet training readi-
ness: a perspective from East Africa. Pediatrics 1977;60:170-7.
21. Cheng TL, Savageau JA, Bigelow C, Charney E, Kumar S, DeWitt
TG. Assessing mothers attitudes about the physicians role in child health
promotion. Am J Public Health 1996;86:1809-12.
The Journal of Pediatrics August 2006