Evidence Based Interventions for Children with Challenging

Behavior

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Kathleen Hague Armstrong Julia A. Ogg
Department of Pediatrics Department of Psychological & Social
College of Medicine Foundations
University of South Florida University of South Florida
Tampa, FL, USA Tampa, FL, USA

Ashley N. Sundman-Wheat Audra St. John Walsh

School Psychology Department of Pediatrics
District School Board of Pasco County College of Medicine
Land O’Lakes, FL, USA University of South Florida
Tampa, FL, USA

ISBN 978-1-4614-7806-5 ISBN 978-1-4614-7807-2 (eBook)

DOI 10.1007/978-1-4614-7807-2
Springer New York Heidelberg Dordrecht London

Library of Congress Control Number: 2013941039

© Springer Science+Business Media New York 2014

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This book is gratefully dedicated to the
children and caregivers who have taught us
so much, and to the providers who are
committed to ensuring that all children learn
and develop to their best potential.
Contents

1 Common Early Childhood Behavior Problems.................................... 1

Sleep Problems.......................................................................................... 2
Prevalence ............................................................................................. 2
Guidelines ............................................................................................. 3
Feeding Issues ........................................................................................... 4
Prevalence ............................................................................................. 4
Guidelines ............................................................................................. 5
Colic/Excessive Crying ............................................................................. 6
Prevalence ............................................................................................. 6
Guidelines ............................................................................................. 6
Toileting Issues ......................................................................................... 8
Prevalence ............................................................................................. 8
Guidelines ............................................................................................. 8
Fears, Worries, and Anxiety...................................................................... 9
Prevalence ............................................................................................. 9
Guidelines ............................................................................................. 10
Sexual Behaviors....................................................................................... 12
Prevalence ............................................................................................. 12
Guidelines ............................................................................................. 13
Aggression ................................................................................................ 13
Prevalence ............................................................................................. 13
Guidelines ............................................................................................. 14
Social Skills .............................................................................................. 15
Prevalence ............................................................................................. 15
Guidelines ............................................................................................. 15
Cultural Competence ................................................................................ 16
Step 1: Awareness ..................................................................................... 17
Step 2: Reflection ...................................................................................... 17
Step 3: Knowledge .................................................................................... 18

vii
viii Contents

Conclusions ............................................................................................... 18
Assess Your Knowledge............................................................................ 19
2 Early Childhood Development Theories ............................................... 21
Attachment Theory ................................................................................... 22
Cognitive Theory ...................................................................................... 23
Applied Behavior Analysis ....................................................................... 24
Parenting Styles ........................................................................................ 26
Ecological Systems Theory....................................................................... 27
Prevention Model ...................................................................................... 28
Conclusions ............................................................................................... 28
Assess Your Knowledge............................................................................ 29
3 The Prevention Model and Problem Solving ........................................ 31
Primary Prevention ................................................................................... 32
Secondary Prevention/Intervention ........................................................... 32
Tertiary Prevention/Intervention ............................................................... 33
Matching the Level of Care to the Child and Family’s Needs .................. 33
Problem-Solving Process Embedded in the Prevention Model ................ 34
Collaborative Problem Solving ................................................................. 37
Conclusions ............................................................................................... 38
Assess Your Knowledge............................................................................ 38
4 Screening Techniques.............................................................................. 41
Conclusions ............................................................................................... 48
Assess Your Knowledge............................................................................ 48
5 Evidence-Based Practices with Children and Their Caregivers......... 51
Parent/Child Programs: Primary Prevention ............................................. 54
Reach Out and Read.............................................................................. 54
Parent/Child Programs: Secondary Prevention ......................................... 57
Helping Our Toddlers, Developing Our Children’s Skills
(HOT DOCS) ........................................................................................ 58
Incredible Years .................................................................................... 60
Nurse-Family Partnership ..................................................................... 63
Parents as Teachers ............................................................................... 65
Parent/Child Programs: Tertiary Prevention ............................................. 67
Helping the Noncompliant Child Parent Training Program ................. 68
Lovaas Applied Behavior Analysis (Lovaas ABA) .............................. 70
Parent–Child Interaction Therapy ......................................................... 73
Trauma-Focused Cognitive Behavior Therapy ..................................... 75
Multi-tier Programs................................................................................... 77
Triple P-Positive Parenting Program..................................................... 78
Child/Classroom Programs ....................................................................... 81
Commonalities Among Child/Classroom Programs............................. 81
Child/Classroom Programs: Primary Prevention ...................................... 81
Promoting Alternative Thinking Strategies (PATHS) ........................... 81
Contents ix

Second Step........................................................................................... 85
Social Skills in Pictures, Stories, and Songs Program .......................... 87
Tools of the Mind .................................................................................. 89
Primary or Secondary Prevention Programs ............................................. 91
Al’s Pals ................................................................................................ 92
Devereux Early Childhood Assessment (DECA) Program .................. 94
I Can Problem Solve/Interpersonal Cognitive Problem
Solving (ICPS) ...................................................................................... 96
Incredible Years Dina Dinosaur ............................................................ 98
Classroom Programs: Tertiary Prevention ................................................ 101
Early Start Denver Model ..................................................................... 101
First Step to Success ............................................................................. 103
Learning Experiences and Alternative Programs
for Preschoolers and Their Parents (LEAP).......................................... 106
Conclusions ............................................................................................... 108
Assess Your Knowledge............................................................................ 109
6 Behavioral Terms and Principles ........................................................... 111
Reinforcement ........................................................................................... 112
Punishment................................................................................................ 113
Schedules of Reinforcement ..................................................................... 114
Time Out ................................................................................................... 115
Setting Up Time Out ............................................................................. 115
Using Time Out ..................................................................................... 116
Options for Younger Children............................................................... 117
Extinction .................................................................................................. 117
Imitation/Modeling ................................................................................... 118
Using Stories to Facilitate Imitation/Modeling in Novel Situations ..... 120
Shaping ..................................................................................................... 121
Conclusions ............................................................................................... 121
Assess Your Knowledge............................................................................ 121
7 Applying Principles of Behavior ............................................................ 125
The Problem-Solving Process ................................................................... 125
Problem Identification........................................................................... 125
Problem Analysis .................................................................................. 127
Intervention Implementation ................................................................. 129
Intervention Evaluation ......................................................................... 129
Conclusions ............................................................................................... 132
Assess Your Knowledge............................................................................ 132
8 Progress Monitoring ............................................................................... 135
Introduction to Progress Monitoring......................................................... 135
Progress Monitoring Methods................................................................... 137
Rating Scales......................................................................................... 137
Behavioral Observations ....................................................................... 138
Existing Tools ....................................................................................... 138
x Contents

General Outcome Measurements for Preschool ....................................... 141

Creating Your Own Progress Monitoring Tool ......................................... 142
Naturalistic Observation ....................................................................... 142
Systematic Direct Observations ............................................................ 144
Conclusions ............................................................................................... 145
Assess Your Knowledge............................................................................ 146
9 Evaluating Outcomes .............................................................................. 149
Directions for Graphing by Hand ............................................................. 150
Computer Graphing .................................................................................. 153
Graphing with Excel 2007 ........................................................................ 153
Graphing with Excel 2011 ........................................................................ 165
Guidelines for Evaluating Outcomes ........................................................ 178
Continue the Intervention ..................................................................... 179
Modify the Intervention ........................................................................ 179
Discontinue the Intervention ................................................................. 179
Evaluating Outcomes Examples ............................................................... 180
Conclusions ............................................................................................... 182
Assess Your Knowledge............................................................................ 182
10 Summary and Conclusions of Best Practices in Providing
Services for YCCB .................................................................................. 185
Daniel: An Example of Primary Prevention ............................................. 186
Diane: An Example of Secondary Prevention .......................................... 187
Review of Diane’s Case ........................................................................ 189
Elizabeth: An Example of Tertiary Prevention ......................................... 189
Review of Elizabeth’s Case................................................................... 190
Easton: An Example of Tertiary Prevention ............................................. 191
Review of Easton’s Case ....................................................................... 192
Conclusions ............................................................................................... 193

Appendix A: Developmental Milestones References ................................... 195

Appendix B: ABC Chart for Determining a Behavior’s Function ............. 197

Appendix C: HOT DOCS Behavior Chart ................................................... 199

Appendix D: Graphing by Hand ................................................................... 201

Glossary ........................................................................................................... 203

References ........................................................................................................ 207

About the Authors ........................................................................................... 221

Index ................................................................................................................. 223

Chapter 1
Common Early Childhood Behavior Problems

Abstract Challenging behavior in young children is common. It can be difficult for

parents or early childhood professionals to know what behaviors fall within the
typical range of behavior. This chapter outlines the prevalence of common behav-
ioral concerns among young children (sleep problems, feeding issues, colic/exces-
sive crying, toileting issues, fears/worries/anxiety, sexual behaviors, aggression,
and social skills) and outlines guidelines for how to address these concerns.
Strategies to ensure cultural competence in working with a diverse range of families
are also outlined.

Keywords Behavior problems • Behavior disorder • Sleep problems • Sleep

disorders • Sleep hygiene • Feeding problems • Colic • Toilet training • Anxiety •
Fear • Worries • Sexual behaviors • Sexual behavior problems • Aggression •
Parent–child interaction • Social skills • Autism spectrum disorders • Attention-
deficit/hyperactivity disorder • Cultural competence

Behavior problems in young children are common (Williams, Klinepeber, &

Palmes, 2004). Healthy toddlers are extremely active, restless, and impulsive, not
because they have a disorder, but because they need to move about and experience
to learn. Furthermore, each child comes with his or her own temperament, making
for huge variations of personalities, even within families. Providing parents with
basic parenting guidelines can help most families successfully navigate through the
early childhood years. These strategies, such as developing and maintaining consis-
tent routines, removing dangerous temptations, praising desired behavior, and redi-
recting problem behavior, are beneficial to all children.
Even so, approximately 20 % of US children have a diagnosable behavioral
health disorder, and less than 20 % of those in need will receive help (Society for
Research in Children’s Development, 2009; U.S. Public Health Service, 2001).
Upon entering kindergarten, problem behaviors, especially aggression and

K.H. Armstrong et al., Evidence-Based Interventions for Children 1

with Challenging Behavior, DOI 10.1007/978-1-4614-7807-2_1,
© Springer Science+Business Media New York 2014
2 1 Common Early Childhood Behavior Problems

hyperactivity, place children at risk not only for poor academic outcomes but also for
social-emotional and behavioral problems in school which may persist throughout
adulthood (Coie & Dodge, 1998; Dishion, French, & Patterson, 1995; Tremblay,
2000). Thus, it becomes important to differentiate between behaviors that are normal
and will possibly be outgrown and those needing more individualized attention.
It can be difficult to separate typical behaviors of early childhood from those that
would be considered problematic. For example, problems such as sleep difficulties
or short attention spans may be typical with young children, but those issues become
more problematic as children get older. Research suggests that rather than just con-
sidering the behavior by itself, one might want to observe for patterns of behavior
(Mathiesen & Sanson, 2000). For example, early onset behavior problems such as
aggression and noncompliance are more likely to be indicative of later problems if
they are exhibited across settings, including home and daycare, rather than in just
one setting (Miller, Koplewicz, & Klein, 1997).
The next sections provide information on a number of common behavioral con-
cerns in early childhood, including sleep problems, feeding issues, colic/excessive
crying, toileting issues, fears/worries/anxiety, sexual behaviors, aggression, and
social skills. These challenging behaviors were selected for discussion because (1)
they are frequent concerns for young children and their families (prevalence rates
for most is at least 20 %), (2) they are issues presented frequently in our clinical
practice, and (3) these difficulties have been described by other authors as prevalent
concerns in young children (e.g., Young, Davis, Schoen, & Parker, 1998). This
overview is intended to help early childhood professionals know what behaviors can
be expected during the typical course of development, and to be able to distinguish
behaviors which may be indicative of more serious and chronic problems in need of
more intensive intervention. Information about these common concerns as well as
guidelines to promote healthy development are presented.

Sleep Problems

Prevalence

Sleep problems are one of the most commonly reported difficulties in young chil-
dren, and may be associated with a variety of conditions and medical problems.
Sleep is important for renewing mental and physical health, while sleep disorders
can lead to reduced health and in some cases may be life threatening (Luginbuehl,
Bradley-Klug, Ferron, Anderson, & Benbadis, 2008). Research suggests that
between 20 and 25 % of children and adolescents may have a sleep disorder
(Mindell, Owens, & Carskadon, 1999), yet few are screened and treated (Luginbuehl
et al., 2008). Children with developmental disabilities, asthma, and other medical
conditions are at increased risk for sleep problems (Armstrong, Kohler, & Lilly,
2009; Buckhalt, Wolfson, & El-Sheikh, 2007). A number of factors have been
Sleep Problems 3

Table 1.1 National Sleep Foundation Guidelines for hours of sleep needed
Age Hours of sleep
Infants (3–11 months) 9–12 h during the night +
30 min to 2-h naps, 1–4 times a day
Toddlers (1–3 years) 12–14 h
Preschool (3–5 years) 11–13 h
School-aged children (5–12 years) 10–11 h (children typically do not nap after 5 years)

associated with disturbed sleep in young children, including maternal depression,

being introduced to solid foods prior to 4 months of age, attending childcare outside
of the home, and watching TV/videos (Nevarez, Rifas-Shiman, Kleinman, Gillman,
& Taveras, 2010).
The most common sleep problems in young children are difficulty falling asleep,
waking up during the night, or a combination of both (Lyons-Ruth, Zeanah, &
Benoit, 2003). In addition, toddlers and preschool children may have difficulty with
nightmares, night terrors, sleepwalking, and sleep talking (Armstrong, Kohler, &
Lilly, 2009).

Guidelines

According to the National Sleep Foundation (http://www.sleepfoundation.org/), by

6 months of age, infants can learn to sleep for at least 9 h per night, and by 9 months
70–80 % of infants are able to sleep through the night. Table 1.1 outlines the
National Sleep Foundation Guidelines for the amount of sleep needed by children,
and may be used to help parents begin to pinpoint sleep problems and take steps to
improve sleep.
To address difficulty falling asleep, the first step is to alter the child’s sleep hab-
its, often referred to as sleep hygiene. Sleep hygiene includes strategies which can
be used to solve sleep problems and begins with the establishment of a regular
nighttime routine. Difficulty falling asleep can be a pattern of behavior which devel-
ops because the child has connected the action of falling to sleep with something
else, generally related to the parent, such as rocking, being held, nursed, or some
sort of motion, and cannot fall asleep by him or herself. To correct this sleep prob-
lem, parents have to reteach the child to fall asleep with a new set of associations,
such as a blanket or stuffed animal. The process involves developing a relaxing
bedtime routine, followed by gradual separation from the child beginning with
2 min intervals, and brief comforting to let child know he or she is safe. Parents will
find this intervention difficult to follow because their child will protest, and will
need encouragement to stay the course. Most children will learn to sleep on their
own within 5 days of consistent teaching (Ferber, 2009).
4 1 Common Early Childhood Behavior Problems

Even when caregivers are attempting to set healthy routines, limit setting prob-
lems around bedtime generally begin around age 2, when toddlers are naturally
testing limits, and resolve when parents develop consistent bedtime routines and
remain firm in their expectations. Bedtime routines that help children sleep well
include wind down activities such as a warm bath; avoidance of television or other
media before bed; keeping bedrooms cool, dark, and distraction-free; and building
in time for some personal interaction at bedtime, like reading books or saying
prayers. Parents should also avoid giving their child food or drinks containing caf-
feine, or over-the-counter cough medications that contain stimulants.
To address the issue of young children staying asleep during the night, an initial
consideration is nighttime feedings. Nighttime feeding problems are addressed by
gradually reducing the habit of providing the child with food at night. By 6 months
of age, a baby should be able to sleep through the night without feeding or feeling
hungry (National Sleep Foundation, 2010). Nursing babies can wait to be fed in
increasingly longer intervals, until nighttime feedings are eliminated. Bottle-fed
babies are offered one ounce less at each feeding and at less frequent intervals dur-
ing the night, until the problem is resolved. A protein snack shortly before bed for
older children can help ease hunger until morning.

Feeding Issues

Prevalence

Feeding problems are very common, with estimates of prevalence as high as 35 % in

young children (Jenkins, Bax, & Hart, 1980). Feeding issues become evident at dif-
ferent stages of infancy and early childhood, with the prevalence of feeding prob-
lems increasing with age. Four percent of children at 18 months experience significant
feeding problems, while at 30 months this number rises to 8 % (Mathiesen & Sanson,
2000). When moderate feeding problems are considered, 47 % of children at age 18
months are considered by parents to have a problem, while at 30 months, 62 % were
considered to have moderate feeding problems (Mathiesen & Sanson, 2000).
On the extreme side of pediatric feeding issues is failure to thrive. Failure to
thrive is diagnosed in children whose weight falls below the fifth percentile for age
on growth charts (Lyons-Ruth et al., 2003). One to five percent of all pediatric hos-
pital admissions are due to failure to thrive (American Psychiatric Association
[DSM-IV-TR], 2000), providing evidence of how severe feeding problems can
become in young children.
Although there is not clear consensus in the literature, it is believed the feeding
problems in young children can result from organic and nonorganic causes. For
example, physical difficulty with the feeding process can be one organic reason that
children have difficulty getting adequate nutrients through their food. Chronic
Feeding Issues 5

medical issues such as reflux can make eating very painful and set up an aversion to
feedings. Alternatively, some nonorganic feeding problems develop and are main-
tained by problematic parent–child relationships, expectations, and lack of meal-
time routines. For example, children may refuse healthy foods during dinner because
they have learned that they will be allowed to have preferred snacks later.

Guidelines

Most professional guidelines, including those from the American Academy of

Pediatrics (AAP) and the World Health Organization (WHO), recommend breast
milk or formula as the main food for children until 6 months of age. The AAP rec-
ommends that solid foods be introduced no sooner than between 4 and 6 months of
age. The WHO has reported that the introduction of complementary feeding (or
transitioning from breastfeeding or formula to other foods) can be a “vulnerable”
time period for young children. The WHO guidelines suggest that complementary
feeding should begin around 6 months. They also recommend that the nutritional
value of the complementary foods be high and free of possible toxins.
Parents are often concerned with how much food their child should eat, especially
once they start to introduce foods that are not premeasured in jars. The United States
Department of Agriculture (USDA) recommends the following calorie guidelines
for young children each day:
• Around 520–570 calories for children 0–6 months
• Around 676–743 calories for children ages 7–12 months
• Around 992–1,046 calories for children ages 1–2 years
• Around 1,642–1,743 calories for children ages 3–8 years
Beginning at age 2, calories should be obtained from six servings from the Grain
food group, three from the Vegetable food group, two from the Fruit group, two
from the Milk group, and two from the Meat and Beans Group.
In addition to the guidelines for how much to eat, the AAP also offers tips for
dealing with feeding and eating issues:
• Don’t threaten, punish, or force-feed your child.
• Provide structure at mealtime with regard to the timing and seating requirements
for mealtime. In other words, have mealtimes on a regular schedule and require
your child to sit at the table to minimize other distractions.
• Prepare several healthy foods you would be ok with your child eating and allow
them to choose which foods they want to eat.
• Limit the length of time for meals.
• Avoid making special meals for children who are picky. Instead, include one
preferred item in the meal and encourage the child to try other foods.
• Food refusal should not be rewarded by offering snacks or preferred foods.
6 1 Common Early Childhood Behavior Problems

Colic/Excessive Crying

Prevalence

Colic and excessive crying are common problems in very young children (from
birth to about 6 months old). Colic is often defined by “Wessel’s Rule of Threes”
which describes colic as:
• Crying for at least 3 h a day
• For at least 3 days in any 1 week
• For at least 3 weeks
This group of symptoms becomes colic when they occur in an otherwise healthy
infant and when no cause for the child’s discomfort can be identified (Lucassen
et al., 1998). Studies of the prevalence of colic have generated estimates as high as
40 % of young children, but most estimates indicate that between 14 and 19 % of
families seek assistance from a physician (Lucassen et al., 2001). The prevalence of
colic decreases with age, as one study found that up to 29 % of infants between 1
and 3 months had colic, but once a child is between 4 and 6 months old, the preva-
lence drops to 7–11 % (St. James-Roberts & Halil, 1991). The cause of colic is often
unknown and may include painful intestinal contractions, lactose intolerance, food
allergies, gas, or have no physical cause at all. In addition, a parent may perceive
normal amounts of crying as being in excess (Lucassen et al., 1998).

Guidelines

There are few effective interventions for colic, and most cases resolve without inter-
vention by 6 months of age. However, several reviews have examined the effective-
ness of common interventions used to (1) lessen a child’s crying and/or (2) lessen
parent anxiety over the child’s crying (Joanna Briggs Institute, 2004; Lucassen
et al., 1998, 2001). Interventions for colic are often divided into three categories: (1)
pharmaceutical interventions, or giving medicine to the infant; (2) dietary interven-
tions, or altering the diet of the child or breast-feeding mother to reduce the exis-
tence of certain allergens, and (3) behavioral interventions, or the changing of parent
behavior in reaction to the infant’s crying (Joanna Briggs Institute, 2004). The
Joanna Briggs Institute has evaluated interventions falling under all three of these
categories to determine if they could be categorized as being possibly useful, having
no effect, or having possibly harmful effects (Joanna Briggs Institute, 2004).
“Possibly Useful” interventions have been found to be at least moderately effective
across several studies. “No Effect” refers to interventions where either no effect was
found or the evidence is very mixed. Finally, the “Possibly Harmful” interventions
have evidence of harmful effects or potential harmful effects, as well as limited sup-
port for their effectiveness in lessening crying.
Colic/Excessive Crying 7

According to the Joanna Briggs Institute (2004), there are no pharmaceutical

interventions that are potentially useful. In contrast, some medications (Simethicone)
have been shown to have no effect, while others may actually be harmful
(Anticholinergic drugs, Methylscopolamine). With regard to dietary interventions,
several have been shown to be possibly useful (low allergen diet for breast-feeding
mother, low allergen formula milk, soy substitute formula milk, and sucrose solution
for short term of relief); several other interventions have been shown to have no effect
(elimination of cow’s milk from breast-feeding mother’s diet, lactase supplement/low
lactose milk, fiber-enriched formula). Behavioral interventions that have been shown
to be possibly useful are reduced stimulation and improved parental responsiveness,
while increased carrying, car ride simulators, and focused parent counseling have
been shown to have no effect. Early childhood professionals should recommend that
families consult with their pediatrician first to address colic; however, knowledge of
effective and potentially ineffective or even harmful interventions can help early
childhood professionals be prepared to work with families of children with colic.

Colic/Excessive Crying Vignette

Annie has been listening to her 6-week-old daughter Leah cry for over 2 hours.
Annie feels upset and frustrated because she has changed Leah’s diaper, made
sure she did not have gas, and tried to feed her. Realizing her nerves are shot
and she needs a break, Annie lays Leah down in her crib, turns on her video
baby monitor (with the sound off), and closes the door to Leah’s room. Annie
decides to take a few minutes for herself and walks outside and sits on her
patio drinking hot tea. After 15–20 minutes, Annie is feeling better and returns
inside to check on Leah. Although Leah is still crying, Annie reminds herself
that this is just a phase that many children go through and it will hopefully be
decreasing over the next few weeks.

In addition to these suggestions, another resource is the program The Period of

Purple Crying (http://www.purplecrying.info/). The website and program was cre-
ated by the National Center on Shaken Baby Syndrome (NCSBS) and has sugges-
tions for parents to help them cope with the stress of having a child who has colic.
The website suggests that colic is typical, although the intensity may vary for each
infant, and provides strategies parents can use to both meet their baby’s needs and
reduce their own stress. The program recommends that after checking to make sure
that the baby’s needs are met (fed, burped, clean diaper, etc.) and the baby is still
crying caregivers should trade off care. If only one caregiver is available, after mak-
ing sure the baby’s needs are met, the caregiver should lay the child down in his or
her crib (on his or her back) and take a 15 minutes break to calm himself or herself
down. After caregivers are feeling calmer, they can return to their normal caregiving
activities. This recommendation comes as a way to prevent Shaken Baby Syndrome,
where parents resort to shaking their infant out of frustration over his or her crying.
8 1 Common Early Childhood Behavior Problems

Toileting Issues

Prevalence

Toilet training is a major milestone achieved by young children and anticipated by

parents. Since the 1950s, the age at which children are expected to be potty trained has
increased from 2 to 3 years old (Schum et al., 2002). Based on a survey of the parents
of approximately 300 children, Schum and colleagues suggest that most children are
ready to be potty trained between 22 and 30 months, and most children are able to stay
dry during the day just before their third birthday (Schum et al., 2002). Research has
suggested that children who start potty training earlier will be potty trained earlier
than their peers; however, the process takes longer to complete when started with
younger children versus older children (Blum, Taubman, & Nemeth, 2003).
The age at which children are potty trained can vary across genders. Schum et al.
(2002) examined the average age that boys and girls are able to engage in different
types of toileting behavior ranging from “staying BM-free at night” to “wipes poop
effectively by oneself.” The study looked at a series of 26 skills and found that girls
on average mastered 25 out of 26 toileting skills before boys. The order in which
children learned the skills was very similar across genders. Girls were dry during the
day by 32 months, while boys met these criteria at 35 months. The lowest level skill
in the study (“staying BM-free during the night”) occurred on average for girls at
22.1 months and at 24.7 months for boys. The most complex skill of “wiping poop
effectively by themselves” occurred at 48.5 months for girls and at 45.1 for boys.

Guidelines

Toilet training will be more successful if parents wait until their child shows global
readiness skills, which include both developmental and physical readiness for being
trained. The first signs are developmental readiness, such as the child being able to
sit on the toilet, understand words for potty functions, and wanting to be indepen-
dent (Schum et al., 2002). Physical readiness for toilet training includes bladder
control and expressed discomfort with soiled diapers (Schum et al., 2002). Even
when a child presents these global readiness skills, there may be times when parents
might want to postpone toilet training, for example, during major life transitions,
such as the birth of a sibling or a move, or during developmental phases when the
child is most resistant.
There are a variety of strategies that can be used to promote successful toilet
training, which are recommended by the AAP (1999) and Azrin and Foxx’s (1974)
Toilet Training in Less Than One Day. Some parents may prefer the more casual
approach recommended by the AAP, during which parents gradually introduce the
potty and allow the child to set his or her own schedule. Praise and positive attention
make going to the toilet fun; however, one should expect occasional accidents. For