Excerpt from Diaper-Free Before 3

My Story

I had no particular interest in potty training during my residency. In fact, I never contemplated that it could be a topic of fresh controversy. Much of my pediatrics training took place at a large American inner city hospital with patients from many countries and socioeconomic backgrounds. We learned about unique parenting customs practiced all over Europe, Asia, Africa, Latin America, the Caribbean, India and more, all from stories shared by parents and grandparents, aunts and uncles. Many of these customs were fascinating. I heard very often about how children elsewhere were potty trained at much younger ages than we were recommending, but I attributed these stories to fault of memory (after all, who really remembers when her 40-year-old child last wet his bed?) and exaggeration. When I saw a family with their toddler in underwear, I thought it was because they could not afford diapers. I remember many physicians telling me that it was not possible to "really" potty train (I did not question what "really" trained meant until much later!) children before two years of age and I accepted that as fact.

Often there was a conflict apparent at an office visit between a grandmother who was trying to potty train the baby and the mother who wanted to do it the "new" or the "American" way. The mother of the baby would roll her eyes at the baby's grandmother, and tell her that with her method of early potty training it was the parents who were trained, not the baby. Faced with these situations, I referred to the American Academy of Pediatrics guidelines regarding toilet training. These guidelines reflect what has been called a "child-centered" approach, most famously advocated by Dr. T. Berry Brazelton in 1962. The basic idea behind this method is that children show various signs (related to their overall development) when they are "ready" to be trained. Proponents of the child-centered approach argue that failure to wait for these signs to emerge before initiating toilet training can cause stress and lead to problems with accidents and toileting refusal at later stages.

Because of this background, I expected that potty training would not emerge for me as a parenting task until my son was walking and talking. But fate (or luck, depending on how you look at it) changed the course of things when he was about six months old. My husband's family came from Serbia, and we hired someone from the "old" country to care for our son when I returned to work. She was unbelievably good with me when I felt the pangs of new motherhood and those painful first separations from my baby, and I loved and trusted her completely.

When she wanted to start sitting my son on the potty at six months old, I said no and my husband and I had a good laugh at her "crazy" ideas. But she was so patient and persistent, and loved us all so much and so well, that we finally agreed to let her "try" to sit him on the little potty chair when he was almost nine months old. The rule was this: she could try to sit him on the potty once a day for a story as long as he was enjoying it. At the time, I didn't expect him to sit on that little potty at all, much less to enjoy it, and I expected her to forget about it very quickly.

But I was wrong. In fact, he was so happy and satisfied sitting on that little chair, and the results were so amazing, that soon we were all hooked. My partners at work told me that I was going to regret it, that early training led to later resistance and refusal. So I decided to read everything I could get my hands on about toilet training-and there turned out to be a lot. Information about toilet training practices has been recorded since antiquity, documenting variations with regard to initiation of toilet training, methods and outcome. The changing trends reflect the thinking of many great minds from the ancient world to the Enlightenment, the Behaviorists to the psychoanalysts, the modern pediatric forefathers Sears, Spock, and Brazelton to the writings of Maria Montessori. Additionally, many experts have published studies comparing toilet training methods in different Western and non-Western countries that shed light on this issue in a broader and extremely fascinating context. (To read the findings, see chapter 2, "Life Before Disposable Diapers".)

In the end, I felt adequately informed to continue to train my son at his young age. Between eighteen and twenty-four months old, he was reliably dry in underwear in all settings (including birthday parties!). Yet the goal was never to train him as early as possible, but to do it in a pleasant, natural and loving way that would feed and fuel his innate desires and abilities. He was never frustrated, and it was much easier to deal with a wet 18-month-old who occasionally needed a quick change into some dry pants than it is to help a three-year-old who is mad and frustrated and embarrassed about an accident that all of his playmates have noticed. We went on to train my second son with the same approach and same results, and that probably would have been the end of it were it not for two separate ongoing processes that influenced my desire to write it all down.

Why I Wrote this Book

The first of these factors was my colleagues' reactions to my personal experiences and newly acquired broad knowledge on the topic. It became a well-deserved running joke that I was obsessed with potty training, and I became a sounding board for everyone's potty training experiences. I was amazed at the number of wonderful, experienced pediatricians who would dismiss any suggestion that earlier introduction of the potty is effective and short-circuit any discussion about the topic. I routinely received comments from colleagues that included: "You can't train a child before he or she is ready", "The children will resent you", "They will regress later and wet the bed" and "At that age, the adults are trained, not the child." These same comments persist and are repeated with predictable regularity, it is almost impossible to believe that they are all well established (many, many times over) in the medical literature to be completely false!

The second factor that contributed to my desire to write this book is the increasing delay in age of toilet training, the many problems this has created for both caregivers and children, and the medical problems that are on the rise as a result. The average age of training in this country is over three year of age, and recent studies show a continued trend toward increasing delay. It is now common practice for parents to wait for their children to ask them before they introduce the potty at all (despite the fact that this practice goes well beyond even Brazelton's liberal recommendations). This is in sharp contrast to the fact that in all that is written about toilet training throughout history, up until the 1950s in this country, potty training was generally completed in the first two years of life.

Today, parents find that not only are they and their children frustrated, many preschools refuse to take children in diapers at all. The problems have been personified for me in the faces of all the discouraged mothers and fathers in the office with their three-year-old children, who are ready to start preschool, able to hang from monkey bars, sing the alphabet, tie their shoes, and even copy shapes, but are still in diapers and show no interest in using the toilet. This is a bizarrely incongruous developmental situation. Clearly these children are "able" to be trained, but parents have been taught to fear "pushing" the issue. Many have not even purchased a potty for the child, as he or she does not "seem interested". Most are not even aware that their situation represents a radical departure from basic and centuries-old child-rearing practice that has potentially serious consequences.