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Am Fam Physician. 2005;71(7):1403-1404

Few studies have been designed to elucidate toilet training difficulties. Schonwald and colleagues identified child and parent characteristics associated with toilet training difficulties.

Parents whose children were referred to a center for a variety of toileting problems filled out a temperament, parenting, and toileting questionnaire, through which 46 children with toilet training difficulties were identified. These “difficult toilet trainers” (DTTs) were three and one half to four years of age and were not trained despite a six-month effort, or they were older than four years but younger than seven years and refused to use the toilet or had not achieved daytime continence of urine or stool. Sixty-two comparison children were drawn from five local preschools. A survey assessed temperament, parental discipline style, and toileting details.

Forty-two percent of the comparison group had easy temperaments compared with 2 percent of the children in the DTT group. In terms of temperament characteristics, children in the DTT group were less adaptable, had more negative mood, were less persistent, and did not approach others. Parenting styles were similar for the two groups, although the DTT group showed a trend toward more dysfunctional parenting. Children in the DTT group were more likely to be constipated compared with children in the other group (78 versus 55 percent). Children in the DTT group also had more fears about toilet training than children in the comparison group.

This is the first study of its kind to document the association between difficult toilet training, constipation, and temperament. Although it is unclear whether constipation is a cause or an effect of toilet training refusal, it should be treated when addressing DTTs.

The authors conclude that although children in the DTT group are temperamentally more difficult, the parenting styles are not significantly different. The authors acknowledge that selection bias might influence these results because only 36 percent of parents in the comparison group responded to the survey.

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