Potty training has been a feature on this blog as part of our overall philosophy that ”Babies are a lot smarter and more capable than we give them credit for”. I felt that the following article was important for me to write in order to help parents who might have been confused after reading the literature of a urologist named Dr. Hodge who claims that potty training before age 3-4 is going to harm your child in serious ways. As a disclaimer, I personally believe that “early” (before age two) potty training has a lot of benefits to it, but that does not mean that if you choose to potty train later you are a bad parent or that your child is not as smart as someone who learned earlier. Potty training is an amoral [neither moral nor immoral] issue, and is a learned skill, not a measure of intellectual capacity, achievement, or parental success/failure. I hope that is very clear.
Last June, Babble published Dr. Hodge’s “The Dangers of Potty Training Too Early: a doctor’s case for training in later childhood“. As I read it, my jaw was almost to the floor, in disbelief that an educated MD could be so historically and globally closed-minded.
In it he claims:
- Potty training should not be initiated before ages three or four under almost any circumstance. His now famous quote, ”Children under age 3 should not manage their own toileting habits any more than they should manage their college funds“.
- Based on his anecdotal work in his urology clinic, he believes that the fate of “early” potty trainers (those trained before age three, which is a pretty poor definition of “early”, it should say “normal” potty trainers) is to suffer from constipation, urinary tract infections, bedwetting, incontinence, kidney infections, and basically every toilet-related problem known to man.
- Diapers or Pull-ups are good for your child’s development until in some cases almost kindergarten: ”the bladder needs about three or four years to grow and develop, and uninhibited voiding (read: diapers) facilitates maximum growth“
Phew. Those are some really scary accusations for a parent to consider. But are they true? Are parents who teach their child to use the toilet before age three doing irrevocable, selfish damage to their poor baby’s body?
Damien at 22 months
Here’s the thing.
If this article would have been written at any time in all of history except the last 2-3 decades, the people this man was preaching to would have looked at him like he had three heads and laughed him out of business. “What do you mean, wait until they are three or four? Why would anybody do that?” It would be similar to someone approaching parents today and telling them that they should keep their children in diapers until age eight. Nobody would take the person seriously, no matter how much “good” reasoning they offered.
The concept of waiting until age 3-4 to potty train is brand new. It is newer than the internet. It is newer than cell phones. Never at any time in all of history have we wrapped our developmentally normal 3-4 year olds in diapers and called it a day. It was completely unheard of until very, very recently.
If you took all of the children in all of history and divided them into those who were potty trained before age three and those who were potty trained after age three, you would be looking at well over 99% of humans falling into the “before age three” category.
Yet, this one doctor is claiming to be so enlightened, that he knows better than almost every parent in all of human history, and knows better than almost every parent around the world to this day: globally, over half of children are potty trained by their first birthday, and another huge portion are potty trained at ages 1-2.
I can only imagine the tiny remaining fraction of current global children who are still in diapers on their third (much less fourth) birthday, yet according to Dr. Hodge, all of these other parents are wrong, and he, because of his experience in his urology clinic, is right.
Damien at 22 months
Dissecting his arguments:
Why American Children’s Potty Training Should Be SO Different In another article he wrote for the Huffington Post, Dr. Hodge does address the argument that has been pointed out about him ignoring historical and global practices, but he brushes it off as irrelevant. He says, “I treat kids who live here and now“, and then goes on to say why our time (and place) is supposedly so different than everybody else in all of the world for all of history:
- Different diets. He says that American children are ”eating Froot Loops for breakfast, snacking on Fritos, lunching on chicken nuggets and chocolate milk and eating mac and cheese for dinner“, so in essence, eating nothing but low-fiber foods, which makes them prone to constipation. First of all, not everybody in America feeds their kids nothing but junk food. Secondly, wouldn’t it be more common sense to educate parents on feeding their children properly to avoid constipation and all the problems it causes, rather than making a harsh blanket statement that says it is bad, bad, bad to potty train before a child’s third birthday?
- Toilet access. He claims that our culture is so different because we actually have to use a toilet. In other cultures, he claims elimination happens anywhere and everywhere: “you don’t need to worry about finding a toilet (behind a bush will do)“. First of all, this is not true. Humans have never just gone wherever they felt like it. Even in very primitive cultures, a designated place for toileting is always established for hygienic purposes, even it it is just a hole behind a tree, it is not just “wherever and whenever”. All mammals avoid eliminating where they eat or sleep, and avoid eliminating in a location where they would step on it and track it to where they eat and sleep, and humans are no exception. Secondly, the cultures who practice “early” (before one year old) potty training are not all bushmen living in the desert. Most are living in suburban or urban dwellings. Thirdly, finding an appropriate bush or making your way to the outhouse is actually more time-consuming and difficult than walking the ten steps it takes to get to the bathroom and use an indoor toilet. Walking to a potty chair that is located right next to where the child is playing is even easier.
- Kids here go to daycare and preschool. His third argument is that our culture is different because in the cultures who potty train young, the children are at home all day and don’t have to go to daycare or preschool. First of all, again, not true. It is not just primitive cultures who practice early potty training. Secondly, while potty accidents in the daycare/preschool setting are common (for reasons he mentioned, such as being shy about telling a teacher they need to go to the bathroom), that does not make it impossible or even impractical for 3-4 year olds to be expected to be out of diapers. Part of the everyday routine in daycares and many preschools is bathroom times where children are reminded to go to use the toilet. And while it is reasonable to expect an adjustment period where a few accidents occur when children start going to preschool for the first time, it is not reasonable to assume that no child should be expected to be out of pull-ups until almost kindergarten. Imagine the burden on kindergarten teachers if it were common for most children to have only been out of diapers for a few short months by the time they start elementary school, which is what this doctor is promoting. The children will not have had hardly any experience or practice in handling their own toileting needs, and the teacher would be responsible for devoting an enormous amount of time dealing the issues of newly potty trained children, and less time actually teaching them.
Using the toilet at 19 months
Some other arguments that he brought up, and my dissections:
- Potty training is going to cause chronic holding, the root of all toileting problems. Dr. Hodge give us a crash course in chronic holding and all of the problems that it can cause (constipation, urinary tract infections, incontinence, kidney infections, betwetting, and more). And in this he is absolutely correct! However, where he isn’t correct is where he makes the preposterous jump to say that all children who are potty trained before age three will develop chronic holding, and this is absolutely false. This study clearly demonstrated that earlier age of toilet training initiation was not associated with “constipation, stool withholding, or stool toileting refusal”, and, again, the experience of 99% of the world’s children throughout history tells us that normal (before age three) potty training, in and of itself, is not going to make your child prone to chronic holding and toileting problems.
- “Uninhibited voiding” (eliminating constantly without ever holding it) is necessary and ideal for proper development. Again, look at history. Look at the rest of the world. This is a ridiculous, non-scientific claim that “uninhibited voiding” is beneficial or necessary for any period of time, much less the first four years. Secondly, as most people who have experience with young children know (as I learned doing daycare for years), most children somewhere around 12-24 months will start holding their urine and/or feces for hours on their own accord. It is completely natural for children to start staying dry during nap times, or to not poop when they are in their car seat, or to even stay dry/clean while they are in an unfamiliar place (many children, still in diapers, prefer to only go in a certain, private place), all without anyone ever telling them to do so. Even if uninhibited voiding was ideal or healthy (no studies or common sense evidence says it is), children naturally stop practicing it usually before their second birthday, so to keep children in diapers until age three or later for this imaginary, unproven benefit is useless.
- Bladder damage. Exercising your sphincter, he claims, is going to ruin it. Supposedly, each time your child holds his sphincter to avoid peeing his pants, his bladder is going to get stronger, harder, and more resistant, which will result in incontinence and bladder infections down the road. He tries to claim that this is unavoidable and is the “definition” of being potty trained, so it’s best to hold off this damaging process for as long as possible. First of all, if what he says is true (that exercising the sphincter is making it hard, resistant, and damaged), then everybody would have a damaged bladder. It wouldn’t matter if you started training at age one or four, within a few months/years of being potty trained everybody should have a messed up bladder and be incontinent and plagued with infections. But it’s not true, because just being potty trained does not damage your bladder. The only thing that is damaging is chronic holding, which as this study mentioned, is not more likely to happen in earlier potty learners. Bladder problems such as infections and incontinence are actually more common in later potty learners (here, here, here, and others). The evidence says exactly the opposite of what he is claiming.
- Kids in diapers rarely get constipated or urinary tract infections, in my experience. Maybe in his anecdotal experience in the urology clinic, but ask almost any doctor: those are both common problems for kids in diapers. This is a completely unfounded and scientifically irresponsible claim.
Sitting on the potty at 20 months
- If you wait until your child is older (age 3-4), they will be mature enough to know the importance of going to the bathroom as soon as nature calls and not hold it. I’m sorry, but in general, three year olds are not mature enough to choose going to the bathroom over continued playtime. They still need to be reminded to go to the bathroom regularly. If we actually waited until they were mature enough to demonstrate this level of responsibility, we might be waiting until they’re teens. I know many adults who put off using the restroom virtually all day, how can you expect a three-year-old to practice more responsibility than many grown-ups?
- Most of the children I see in my office with problems were potty trained before age three. Since most kids are potty trained before age three, you would expect to see a similar proportion of children with problems in your office.
- Toileting problems are on the rise! We need to stop with all the pressure to potty train earlier and earlier! The average age of toilet training has gotten later and later steadily throughout the years, and is almost twice what it was 50 years ago. The “pressure” for parents to potty train at a historically typical age (1-2) is virtually nonexistent, and in fact, there is currently more pressure to wait until your child is older than there is to start “early”. The fact that toileting problems have increased as the age of potty training has increased, can be more reasonably seen as evidence against his theory, not evidence supporting it.
- All the studies pointing out the downsides of potty training later and the benefits of potty training earlier are wrong. He claims every single study about the association of later potty training with future problems is flawed because “The authors didn’t check, via X-ray, to see if these kids were constipated at the time they started training“. I get that constipation can cause a lot of problems. But, in general, if countless studies have linked later potty training with future problems, we might have something going here. Sure, they didn’t factor in one small aspect that could have possibly been to blame for problems in some of the cases, but that does not completely negate the findings by any means. They still, many times over, found a relationship, and it is silly and scientifically irresponsible to try and claim that every single potty training struggle has to do with constipation: it doesn’t.
- Bonus: your child’s poop should look like chocolate pudding before you start potty training. This statement probably has the ability to freak out a lot of parents (what? my child’s poop doesn’t look like that, something must be wrong!), but I’d take it with a grain of salt and talk to your child’s doctor before worrying, as I’ve never known a child past early infancy to have poop like this.
Damien wearing underwear at 14 months old
I don’t believe that a single one of Dr. Hodge’s arguments against potty training before three hold up to any kind of scientific or common sense scrutiny and, in fact, almost all of his arguments are the opposite of what scientific studies (and all of human history) have demonstrated.
Dr. Hodge is doing a lot of good work in his practice with the children in his clinic, and it would probably be best for him to stick to that. It seems to me that in his zeal for curing all problems by reliving constipation, he is starting to see connections where there aren’t any, imagine correlations and causations, and take his anecdotal observations of a very limited, abnormal subset of children (kids who need a urologist) and paint them as a representation for the entire country or world. A dangerous place to be, if you ask me.
If he would stick to what he is good at, he actually has a lot of valuable things to teach us. Like, “Hey parents, toileting problems in children are on the rise. Certain things about our culture and lifestyle are making those problems more prone to happen. Make sure your child eats a very high-fiber diet. Watch your child carefully for holding behaviors and make sure they are going to the bathroom regularly whether they want to stop playing or not. If your child has developed certain problems, take them to a urologist and be sure they x-ray their colon.”
See? Wouldn’t that have been more effective and helpful than essentially saying, “If you potty train at a normal age like all humans have done for all of history and almost all humans currently still do at this very moment, you are going to harm your child in awful, painful, detrimental ways“?
But, I guess that wouldn’t have caused such a stir and the corresponding publicity and page views.
I feel sorry for all of the thousands of parents who have read Dr. Hodge’s advice and fearfully thought, “Wow, well I don’t want to damage my kid! Potty training before three must just be a selfish parent’s excuse for not wanting to change more diapers. I am definitely going to wait until my child is older!“, not realizing that according to science, they are actually heading down the path of their child being more prone to long- and short-term problems and more likely to suffer damage.
It’s sad, and I really felt it important to speak out.
What do you think about Dr. Hodge’s accusations? Please remember, I don’t think parents who choose to wait until their child is older before they potty train are bad parents, I just want parents to be informed and make their choices based off of solid reasoning and real scientific research, not unfounded fear tactics. Would love for you to share your thoughts!