Eur J Pediatr (2012) 171:955–961

DOI 10.1007/s00431-011-1665-5

ORIGINAL ARTICLE

Toilet training in daycare centers in Flanders, Belgium

Nore Kaerts & Guido Van Hal & Alexandra Vermandel &
Jean-Jacques Wyndaele &
The participants of the learning study group

Received: 21 October 2011 / Accepted: 19 December 2011 / Published online: 30 December 2011
# Springer-Verlag 2011

Abstract Several changes have occurred in the toilet train-
ing (TT) process in recent decades. There has been an
increase in the use of daycare as both parents now often
work outside the home. Most children attend daycare cen-
ters during the period TT usually takes place, and daytime
training has shifted from home to daycare. This study is the
first to evaluate the way TT is done in daycare centers. A
questionnaire was sent to 1,500 daycare centers, of which
429 replied (response rate of 28.6%). The results show that
half of the childcare workers base the decision to start TT on
readiness signs. The combination of age and readiness signs
is used by 44.5%. The majority of the respondents spent
more than 1 h per day on TT (81.8%); 79.8% considered
that daycare and parents should play an equal role in TT.
However, more than a third of the respondents thought that
parents pass the responsibility for TT on to daycare and that
not enough attention was paid to TT in the home. Most
respondents stated that daycare centers had the facilities
and means to be able to give the children proper TT
(88.5%). Other research indicated that the outcome of TT
N. Kaerts : A. Vermandel : J.-J. Wyndaele
Department of Urology, Faculty of Medicine, University of Antwerp,
Antwerp, Belgium
G. Van Hal
Department of Epidemiology, Faculty of Medicine,
University of Antwerp,
Antwerp, Belgium
A. Vermandel : J.-J. Wyndaele
Urology, Antwerp University Hospital,
Antwerp, Belgium
J.-J. Wyndaele (*)
Urology—UZA,
10 Wilrijkstraat,
2650 Edegem, Belgium
e-mail: jean-jacques.wyndaele@ua.ac.be
is not that good overall and that there is room for improve-
ment in the methods used. More research is needed on the
role division and on the interaction between daycare and
parents and their combined influence on the process and
outcome of TT.
Keywords Toilet training . Child daycare centers . Child,
preschool . Child rearing . Health
Abbreviations
TT Toilet training
RS Readiness sign(s)
Introduction
In the Western world, there has been an increase in the use
of daycare [6, 9, 12, 27, 31, 40, 41, 43]. The European
Union (EU) strives for equal rights and opportunities for
men and women, an increased employment rate for women,
and a better combination of work and family [6, 9, 32]. To
accomplish this, the EU has motivated its Member States “to
provide childcare by 2010 to at least 90% of children aged
between 3 years and the mandatory school age, and at least
33% of children below 3 years of age” [6, 9, 32]. Nowadays,
the majority of the children younger than 5 years regularly
spend their day in daycare [1, 12, 27, 31, 43]. In Flanders,
the need for and presence and use of childcare for children
under 3 years are increasing [24, 25]. The percentage of
Flemish children between 3 months and 3 years attending
childcare regularly rose from 55.7% in 2004 to 63.2% in
2009 [23, 24]. Moreover, raising and educating young chil-
dren is no longer only a task for the family and school, with
daycare becoming more and more accepted as a third edu-
cational environment [23, 25, 41]. Childcare plays an im-
portant role in preparing the children for nursery school.
956
Many parents report being confused and uncertain about
when their child is ready to start TT, and which method to
use [10, 13, 27, 37, 44]. This uncertainty can cause the
parents to start TT too early, or too late, which is known
to lead possibly to stress and frustration for both child and
parents, which is the most important cause of child abuse
and can also lead to social, physical, and psychological
problems and extend the duration of the training process
[1, 2, 7, 15, 36]. In addition, it contributes, together with
several other factors, to a postponement of the TT age [1, 2,
5, 7, 8, 11, 19, 20, 34, 36]. In the Western world, an
evolution towards a later start has been observed in the past
60 years [2, 5, 35]. Such a delay has negative consequences
for health and familial situation, and the increasing amount
of used diapers can lead to environmental and economic
problems [2–5, 7, 13, 16–18, 20, 21, 28, 29, 31, 35, 38, 39, 44].
Now that children spend an important amount of time in
daycare in the period they usually become toilet trained,
daycare centers have also become major partners in the TT
process. Little research has been done on TT in daycare, and
has focused mainly on the health consequences of the post-
ponement of the age at which children are toilet trained [1,
7, 8, 12, 13, 16, 17, 26, 30, 31, 33, 38, 40, 46].
The role of the daycare setting in the TT process is
diverse. Children seem to learn toilet skills more easily by
imitating other children [1, 12, 43]. Childcare workers are in
a good position to recognize when a child is ready to start
TT as they are familiar with this process through experience
and training [1, 43]. They can provide the parents with
information and advice. They can emphasize that the train-
ing methods and expectations at home and in the daycare
center must be similar to avoid confusing the child [1, 43].
When problems occur, childcare workers can identify them
and discuss them with the parents [1].
When communication and synergy are lacking between
parents and childcare workers, questions of accountability,
commitment, and control over the TT process can arise [12,
47]. Childcare workers and parents can then use different
methods or have different expectations regarding TT, which
may confuse the child and may create stress or delay [12,
47]. Parents may assume that childcare workers will play the
biggest role in TT their child, while in reality this may not
be the case [12].
Method
This research was conducted in Flemish daycare centers. We
developed a questionnaire to evaluate the viewpoint of the
childcare providers regarding TT, their role in this process,
and the relation between daycare and parents (Addendum).
We also wanted to obtain a picture of how TT is dealt with
in daycare centers: when TT is started, which methods are
Eur J Pediatr (2012) 171:955–961
used, and how problems are dealt with. After a pilot project
in which the questionnaire was tested by a number of child-
care workers, we made some small adaptations and created
an electronic version. The questionnaire was sent by e-mail
to the daycare centers. In total, 1,500 questionnaires were
sent by July 2009. An e-mail reminder was sent to the
daycare centers that had not responded by September
2009. The responses were entered in a database and ana-
lyzed using SPSS 18.0.
Results
We received 429 completed questionnaires (response rate of
28.6%).
1. Background features of the respondents
Most of the daycare centers (>70%) employed two to
five childcare workers and looked after 11 to 30 chil-
dren. Almost all respondents were women; 33.7% of the
respondents had secondary school seventh year child-
care training, 32.3% had a diploma in higher education,
31.8% had a high school degree, and 2.2% had no
diploma. Most of the respondents (65.1%) had no or
only a few hours (1–5) of education on potty training.
2. Start of the TT process
Half of the respondents replied that they decided the
right moment to start based only on readiness signs
(RS), 4.7% used age as the only criterion. The combi-
nation of age and RS was used by the remaining
respondents (44.5%); 75.4% started at 24 months of
age. The RS used to decide on starting TT are given in
Table 1. Almost no one started at a different age accord-
ing to the gender of the child.
3. Used TT method
The TT methods used are given in Table 2. The most
commonly used method was putting the child on the
potty on a regular basis (94.6%). The majority of the
respondents (81.8%) spent more than 1 h a day on TT
the children in the daycare center. Of these, 67.6% spent
between 1 and 3 h on potty training each day.
4. End of the TT process
The indicators used to define whether a child is
potty-trained are given in Table 3.
5. The relation between daycare workers and parents re-
garding TT
All respondents communicate with the parents about
the TT process of their child. Most of the time this
happened when the parents brought their children to
the daycare or when they came to take them home
(83.2%). It also happened when the child was enrolled
in the daycare center (23.1%) and via meetings between
parents and carers (24.7%). Almost all of the childcare
workers (90.7%) told the parents that the TT had to be
Eur J Pediatr (2012) 171:955–961 957

Table 1 Which readiness signs are used to decide when to start the toilet training? (multiple answers possible)

Readiness sign N0370

n %

The child is motivated and shows interest in toilet training (e.g., following other people to the toilet) 290 78.4
The child can express the need to evacuate (by words, mimicry, and/or gestures) 269 72.7
The child indicates by himself/herself that he/she has a wet/dirty pants 264 71.4
The child can control the bladder in a sufficient way (the child is capable of staying dry for approximately 2 h) 240 64.9
The child controls bladder, sphincter, and bowel movements 223 60.3
The child can express when it has evacuated (by words, mimicry, and/or gestures) 194 52.4
The child understands and uses potty-related words 167 45.1
The child is able to walk and sit 128 34.6
The child realizes that the urge to go to the potty has priority to all other activities 120 32.4
The child is dry after the midday nap 118 31.9
The child asks to wear normal underpants 118 31.9
The child understands and can respond to simple commands of the parents or caregivers 99 26.8
The child is able to pull clothes up and down 53 14.3
The child can say no as sign of independence 50 13.5
The child likes to imitate behavior and actions of parents or caregivers 43 11.6
The child can imitate behavior and actions of parents or caregivers 28 7.6
The child has the desire to please parents or caregivers 28 7.6
The child begins to put things where they belong 15 4.1
The child can independently open and close doors, wipe himself/herself, flush the toilet, and wash and dry his/her hands 14 3.8

continued at home. Data on the TT topics discussed
with the parents are given in Table 4.
Most respondents (92.7%) ask the parents to dress
their children in clothes adapted to TT, for example, in
pants which could easily be removed by the children;
73.9% of the respondents said that no conflicts were
seen with the parents as a consequence of TT; 74.2% of
the parents agreed when starting TT was proposed.
When a refusal had been experienced, it was claimed
that this was due to a lack of time (45.8%) or commit-
ment from the parents (26.2%). Half of the respondents
encouraged such parents to reconsider.

Table 2 Which methods do the

childcare workers use to potty Toilet training method N0407
train the children? (multiple
answers possible) n %

Put the child on the potty on regular time points 385 94.6
Reward the children when they cooperate well with the toilet training 322–383 79.1–94.1
or when they had a successful potty moment
Remove the diaper during the day or during parts of the day 305–366 74.9–89.9
Regularly ask the children whether they have to go to the potty 286 70.3
Read books to the children on the use of the toilet and the toilet training 238 58.5
process
The applied method differs from child to child 142 34.9
Give a demonstration (show how the children should use the toilet) 67 16.5
Give many drinks to the child 12 2.9
Letting the child press 4 1
Punish the child 2 0.5
Other than the abovementioned methods (e.g., going to the potty in 37 9.1
group to stimulate imitation of already toilet-trained children, looking
for signals the child shows when it has the urge to go to the potty,
encouragement, use same method as parents, adapt clothes, put the
potty in sight)
958
Table 3 Which indicators do childcare workers use to define whether
a child is potty-trained? (multiple answers possible)
Indicators
The child takes initiative when feeling the urge to void
or make a bowel movement (the child warns the
caretaker that it is time to go to the potty or toilet or
the child goes independently to the toilet, without
reminders or encouragement of the caretakers)
The child wears underpants during the day, not a diaper
Depending on the amount of toilet accidents a child has
The child can independently perform activities related
to potty training, like flushing the toilet, washing
hands, pulling the pants up and down, etc.
Most respondents (79.8%) thought that parents and
the daycare center should play an equal role in the TT.
In addition, most childcare workers answered that the
daycare center and the parents decided together when
the potty training process should start (76.7%) and
which TT methods would be used (68.1%). Only 3.9%
of the respondents agreed that potty training should only
be done at home. Most respondents (77.1%) thought
that children became potty-trained faster when there
were other children they could imitate. More than a
third of the respondents thought that parents passed
the responsibility of TT their children on to the daycare
centers, but 40.5% did not hold this view. More than a
third of the childcare workers thought that not enough
attention was paid to the TT process in the home.
6. Facilities and means
Almost 90% of the childcare workers stated that the
daycare center provided enough facilities and means to
be able to give the children proper TT. The number of
potties in the daycare center was sufficient. Further-
more, 72.6% of the respondents acknowledged receiv-
ing sufficient advice from organizations like “Family &
Table 4 Which topics on toilet training do childcare workers discuss
with the parents? (multiple answers possible)
Topics discussed with the parents
The progress of the child
The toilet training methods which are, or will be used
How the parents deal with the toilet training
The attitude of the child
The learning processes taught at home
Other than the abovementioned topics (e.g., advice,
cooperation between parents and daycare, best
moment to start with TT, problems with TT)
Eur J Pediatr (2012) 171:955–961
Child” (“Kind & Gezin”): an autonomic agency and
legal entity under the authority of the Ministry of
N0406 Health, Welfare and Family, which aims to give all
children the best start in life possible, and is in charge
n % of childcare and the organization of preventive support
for families (http://www.kindengezin.be/Images/
367 90.4
20071024decreet_tcm149-52894.pdf); 78.8% of the
carers agreed that the daycare center offered enough
guidelines concerning TT, and 9.6% of the respondents
thought more personnel were needed.
339 83.5
7. Hygiene in the daycare center
224 55.2
Almost all childcare workers (91.6%) were satisfied
100 24.6
with the hygiene in the daycare center and found addi-
tional measures not necessary. The most frequently
mentioned hygiene procedures were hand hygiene
(76.9%) and disinfecting and cleaning the potties and
toilets (52.4%); 16.3% also mentioned disinfecting and
cleaning the room and the objects in the room. These
procedures are transmitted orally or in writing in half of
the daycare centers.
8. Problems with TT
When a child is not able to follow the pace of the
training, experiences too much pressure, or is not com-
pliant (for example, has tantrums or refuses to go to the
toilet), the majority of the childcare workers interrupt
the TT to resume it at a later time (77.6%). Other actions
taken are given in Table 5. The majority of the childcare
workers felt that no other tasks or activities were ham-
pered by the TT (81.3%).
The carers often experienced pressure to speed up TT
(60.4%). Most of the time, this pressure came from the
parents (74%), from the nursery schools (20.4%), or
sometimes from another source (such as other childcare
workers, pediatricians, grandparents, or “Family and
Child” (Kind en Gezin)) (5.6%). Almost all respondents
stated that this pressure negatively affected the TT pro-
cess, and 79.4% did not comply with such demands.
Discussion
N0397
This study is to our knowledge the first to evaluate the way
n % TT is conducted in daycare centers. Our results show that
deciding to start TT is mostly based solely on RS. These
357 89.9 findings are in line with the current recommendations,
337 84.9 which agree on the importance of RS [1, 14]. Starting TT
331 83.4 based only on age can have negative consequences if the
245 61.7 child is not yet ready [1, 2, 10, 14]. A recent literature
206 51.9 review shows that currently consensus is lacking on which
24 6.1 or how many RS are needed to decide on a child’s readiness
for TT [22]. Depending on the RS used, the moment to start
TT can vary a great deal [22]. More research is needed to
Eur J Pediatr (2012) 171:955–961 959

Table 5 What happens when a

child is not able to follow the Actions N0397
pace of the toilet training process
or experiences too much n %
pressure? (multiple answers
possible) Interrupt the toilet training to resume it at a later time 308 77.6
Contact the parents 87 21.9
Continue the training, but pay closer attention to the child (give the child a more 45 11.3
individual training, more encouragement)
Try other toilet training methods 34 8.6
Restart the training from the beginning 13 3.3
Continue the toilet training the same way 8 2
Other than the abovementioned actions (e.g., never pressure/force child 28 7.1
Questionnaire is available on to go to the potty, action differs according to the child, search for causes, training
request from the corresponding according to individual pace of the child)
author

reach consensus, obtain research-based guidelines, and
avoid problems [22].
It is noteworthy that TT takes so much time per day.
A possible explanation may be the used TT method.
Most carers (94.6%) put the children on the potty at
regular intervals, which is a time-consuming method.
Children who just started the TT are often first familiar-
ized with the potty. The child is often put on the potty
four to six times a day in daycare during intensive
training. Moreover, the childcare providers often have
several children to look after. TT time does not only
include the potty moments but also the diaper and train-
ing pants changes.
Almost no one used punishment or asked the child to
push during TT. Research by Bakker et al. [2–4] showed
that when TT is started at a later age, and the child is asked
to strain, or punishment is used during TT, there is an
increased risk of bladder problems when growing up (such
as recurrent urinary tract infections and urge syndrome).
According to the participants, there is good cooperation
and communication between them and the parents, and
efforts are made to provide the child with consistent TT.
Given these positive results, it would be interesting to in-
vestigate whether this cooperation helps to decrease the
uncertainty, stress, and frustration reported by many parents
during the TT phase of their child [1, 2, 7, 10, 13, 15, 27, 36,
37, 44]. It would also be interesting to compare these neg-
ative effects related to TT between parents whose children
attend daycare and those who do not.
Taubman [39] found no correlation between attending
daycare and the age the child was toilet trained. Schum et
al. [36] confirmed these findings. In addition, Schum et al.
[35] found that daycare does not influence the acquisition of
TT skills.
We conclude that the results, in general, reflect a positive
image of how TT is dealt with in daycare centers in Flan-
ders, of the means and facilities available for TT, of the
hygiene and accompanying procedures, of how problems
are resolved, and of the cooperation and communication
between childcare workers and parents.
However, it seems that the current TT practices, despite
the investment of a lot of energy, often do not lead to good
results as many children go to nursery school without hav-
ing completed TT (nursery school starts at 2.5 years in
Belgium) [42]. Previous research [42] showed that more
than a fifth of children who started nursery school had not
completed the TT process, which leads to complications.
Questions must be asked about why this is so. Is the method
used the cause? Is TT started at the wrong time? Is there a
change in the attitude of the parents? Is something going
wrong in the cooperation between parents and daycare or
nursery school? Studies are needed.
The results show that more than a third of the childcare
workers feel that parents pass on their responsibility to toilet
train their child to daycare personal and that more than a
third think there is not enough attention paid to TT in the
home. Earlier research showed that respectively more than a
third and more than a half of the nursery teachers surveyed
shared these feelings [42]. Moreover, 73% of the nursery
teachers stated that opinions on TT have changed [42].
Previous studies showed that parents are less consistent
and authoritarian and more liberal in their education.
They are also short of time, mainly as a consequence
of both working outside the home, which contributes to
the postponement of the TT age [5, 8, 19, 20, 34, 36]. It
is therefore perhaps not surprising that parents rely more
on daycare for their child’s toilet training. Little research
has been done on TT in families, and further investiga-
tion would be interesting.
We can hypothesize that it is most likely the current
general TT practices in our Western Society (time at which
TT is started, method used, attitudes towards TT) that lead
to the identified social, physical, and psychological prob-
lems for the child and negative consequences for health and
familial situation, and environmental and economical prob-
lems [1–5, 7, 13, 15–18, 20, 21, 28, 29, 31, 35, 36, 38, 39,
960
44]. Although childcare workers in daycare centers put a lot
of energy into TT, it seems that the results are not always
that good. Perhaps a change of method would lead to better
results, without increasing the workload. Other and possibly
more efficient methods to TT children have been described
than the ones that are currently most often used in daycare
[43, 45]. Further research on this topic is needed.
The limitations of this study are the following. First of
all, the response rate of the daycare centers to the question-
naire was 28.6%. Therefore, there is a real possibility that
mostly the dedicated and more interested daycare centers
and/or those who use the accepted child-oriented method
filled in the questionnaire. This should be borne in mind
when interpreting the results. In addition, we used a de-
tailed, mainly closed questionnaire, which provided many
possible answers. This could be suggestive in some way and
potentially lead to more reflections on the part of the carers
when responding.
Acknowledgement The participants of the learning study group
contributed to conducting this study. The learning study group con-
sisted of: Floris Adriaenssens, Sara De Bruyn, Marjolein Elsen, Jessie
Horemans, Sofie Lamiroy, Niels Massart, Charlotte Quirynen, Latifa
Talal, Pieter Uytterlinde, Manon Van Aerschot, Leen Van Lier,
Laurence Van den Acker, Elke Verbeelen, Leen Verboven, and Joni
Vleugels.
Conflict of interest The authors declare that they have no conflict of
interest related to this study. Part of one researcher’s salary was paid
out of a grant by Kimberly Clark.
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