Children normally master the steps of toilet training tasks in a general developmental sequence. They typically first learn to notice the signals that they need to go to the bathroom and then how to react in time to handle waking or daytime defecation. It takes longer for children to learn how to handle nighttime defecation (which occurs when they are sleeping). Next, children normally figure out how to react in time to their bodies' signals for daytime urination. Successfully managing nighttime urination is the hardest task for young children to master, and as such, this step may take them the longest amount of time to achieve. Bedwetting is common challenge for families with preschool-aged children. Around 40 percent of 4-year-olds wet the bed several times a week. Nearly 20 percent of 5-year-olds and 10 percent of 6-year-olds have occasional accidents.
Nighttime dryness is almost completely determined by children's degree of physiological (body) maturity. This means that in order for children to stay dry throughout the night, they first have to develop a bladder and muscle system which is large and strong enough to hold a full night's capacity of urine. This is complicated by the fact that children make even more urine throughout the night than they do during the day. Some children have the ability to wake up in the middle of the night to use the bathroom. However, the development of this capacity requires that children's brain mature to the point where they can receive and process bodily signals of impending urination and then wake up in time to make it to the bathroom. In general, the older children become, the more mature their brains are, and the more likely they are to develop this capacity.
While parents can't make their children mature faster, there are a few things they can do to help children make it through the night with fewer incidents. Parents can improve children's nighttime dryness by limiting their fluid intake starting an hour or two before bed. This means that children should not drink lots of water, juice, soda, etc. shortly before bedtime.
Nighttime pottying can be made easier if parents put a portable potty beside children's bedside for easier access. This is especially helpful during the early phases of toilet training when children may only have a few moments between waking and releasing. It is of lesser importance as children mature and can hold themselves back for longer periods of time. Night-lights can be placed at intervals between the bed and bathroom to make a nighttime bathroom trip safer and less scary. For further reassurance, many small children will want to wake up Daddy or Mommy for assistance or for moral support. If possible, parents should continue to support this behavior until children feel comfortable going to the bathroom on their own.
While it it tempting to rush children out of diapers and to promote their independent use of the adult toilet, parents really need to carefully consider whether their children are ready for this treatment. Nighttime diapers or disposable training pants may need to be continued for a time, and should be if this decreases children's nighttime accidents. Children are not generally ready to try sleeping through the night without the assistance of a diaper or training pant until they can stay dry for three to four hours between bathroom breaks during the day. Children who are ready to sleep without training pants will regularly wake up dry in the morning, or will demonstrate that they sometimes wake up in the night and use the bathroom (with or without parental assistance). Children's readiness is not all purely physical either. If children seem scared or upset at the prospect of using underwear instead of training pants at night, it's a sign they are not emotionally ready for this step and parents should consider backing off for a time.
Even if a child shows all the signs that they are capable of going without a diaper through the night, parents should still ready themselves for the possibility of nighttime accidents. Keeping a waterproof mattress pad on the bed is a smart move for all children up through the late elementary years, as it protects the mattress from nighttime wetting accidents, nighttime sickness, and bottles of juice that find their way into bed. As well, clean sheets and pajamas should be kept within easy reach for a quick switch should that be necessary during the night. Older kids, around age six and up, can be taught to change their own sheets, pajamas, and to put the dirty laundry into the designated hamper or storage area. Putting away your own dirty linens should be presented as just another responsibility people have for taking care of their own hygiene, and not as a punishment or discipline strategy. Parents should avoid making comments that are shaming when older children have accidents, and remain matter-of-fact and reassuring, just as is the case whenever any potty accident takes place.
The majority of children will have completed their toilet training by around ages 6 or 7. If bedwetting persists consistently until or past age 6 or 7, or if bedwetting is accompanied by other sleeping problems, parents should consult their family doctor. Moreover, if a child has had mostly dry nights for a long period of time and then suddenly regresses and develops a frequent bedwetting problem again, a doctor should also be notified. Bedwetting that does not resolve could be caused by an infection. Or, if the bedwetting is accompanied by nightmares or other fear reactions, there could be other emotional problems or situations at work. Bedwetting accompanied by fear can be a sign that abuse is taking place, for example.
Encopresis and Enuresis
Children who persistently have problems with soiling themselves may have Encopresis. Encopresis simply means that a child who is developmentally at least four years old regularly ends up pooping in inappropriate places, such as in clothing, or in bed during the night. The inappropriate defecation must occur at least once a month over a three or more month period, and can be voluntary or involuntary. It cannot be as a result of a medical condition, unless that medical condition includes constipation as a side effect. The term Encopresis is just a label that doctors and other clinicians use to describe an age-inappropriate soiling problem; it is not itself a source or cause of a soiling problem.
If children continue to have problems wetting themselves or wetting the bed beyond the developmental age of 5, their doctor may diagnose them with Enuresis. Enuresis is simply a label used to describe children who is at least five years old developmentally, and who regularly urinate in the wrong places or at the wrong time (whether involuntarily or on purpose). This regular urination problem must occur at least twice a week for three or more months in a row. A doctor may also diagnose Enuresis when children are wetting themselves less frequently but the behavior is nevertheless creating significant emotional or social problems at school or home. Enuresis is not diagnosed when a medication or another medical condition is causing the wetting problem. As is the case with Encopresis, Enuresis is not a cause or reason why a wetting problem is occurring; it simply describes that occurrence of this sort of problem.
For more information on how Enuresis and Encopresis are diagnosed and treated, please see our Childhood Mental Health Disorders article.
While hardly a simple task for small children to learn, toilet training doesn't have to be an overwhelming experience for children or for their parents. With a little knowledge, preparation, sensitivity, and creativity, a few tools and materials, and a whole lot of love, patience and enthusiasm, parents can help their little ones along the winding path towards their ultimate success as fully toilet trained children. Children's successful mastery of toilet training dramatically increases their independence, making it possible for them to attend school and community programs and to interact with school-aged peers for extended periods of time.