The effectiveness of different methods of toilet training for bowel and bladder control.

Objectives: The objectives of this report are to determine the following: (1) the effectiveness of the toilet training methods, (2) which factors modify the effectiveness of toilet training, (3) if the toilet training methods are risk factor for adverse outcomes, and (4) the optimal toilet training method for achieving bowel and bladder control among patients with special needs.

Data sources: MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid OLDMEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, PsycINFO, ERIC, EBM Reviews, HealthSTAR, AMED, Web of Science, Biological Abstracts, Sociological Abstracts, OCLC ProceedingsFirst, OCLC PapersFirst, Dissertation Abstracts, Index to Theses, National Research Register's Projects Database, and trials registers.

Review methods: Two reviewers assessed the studies for inclusion. Studies were included if they met the following criteria:

Study design: RCT, CCT, prospective or retrospective cohort, case-control, cross-sectional or case-series;

Population: infants, toddlers, or children with or without co-morbidities, neuromuscular, cognitive, or behavioral handicaps disabilities;

Intervention: at least one toilet training method; and

Outcome: bladder and/or bowel control, successes, failures, adverse outcomes. Methodological quality was assessed independently by two reviewers. Data were extracted by one reviewer and a second checked for accuracy and completeness. Due to substantial heterogeneity, meta-analysis was not possible.

Results: Twenty-six observational studies and eight controlled trials were included. Approximately half of the studies examined healthy children while the remaining studies assessed toilet training of mentally or physically handicapped children. For healthy children, the Azrin and Foxx method performed better than the Spock method, while child-oriented combined with negative term avoidance proved better than without. For mentally handicapped children, individual training was superior to group methods; relaxation techniques proved more efficacious than standard methods; operant conditioning was better than conventional treatment, and the Azrin and Foxx and a behavior modification method fared better than no training. The child-oriented approach was not assessed among mentally handicapped children. For children with Hirschsprung's disease or anal atresia, a multi-disciplinary behavior treatment was more efficacious than no treatment.

Conclusions: Both the Azrin and Foxx method and the child-oriented approach resulted in quick, successful toilet training, but there was limited information about the sustainability of the training. The two methods were not directly compared, thus it is difficult to draw definitive conclusions regarding the superiority of one method over the other. In general, both programs may be used to teach toilet training to healthy children. The Azrin and Foxx method and operant conditioning methods were consistently effective for toilet training mentally handicapped children. Programs that were adapted to physically handicapped children also resulted in successful toilet training. A lack of data precluded conclusions regarding the development of adverse outcomes.