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Maternal expectations and attitudes toward toilet training: A comparison between clinic mothers and private practice mothers
B E H A V IO R A L P E D IA T R IC S
RichardW. Olmsted, Editor
Maternal expectations and attitudes toward toilet training: A comparison between cl&ic mothers and private practice mothers Mothers at inner city clinics differfrom middle-class suburban mothers with private pediatr&ians in the#" attitudes and expectations regarding toilet training, such as the ideal age to initiate bladder and bowel training, ideal age for completion of toilet training, response to the child who soils after a program Of toilet training has been initiated, and source of i n formation to guide in toilet training. Possible explanations to account for these differences are explored," the implications for training health personnel are discussed.
Susan S. Carlson, M.D., and Russell S. Asnes, M.D.,* New York, N.Y.
PEDIATRIC house officers, nurses, and medical students often learn "acceptable practices" of toilet training from attending pediatricians, pediatric textbooks, and articles on well-baby care. Parents may seek such information from the medical staff or the subject may be explored in the context of providing preventive health care. In addition, a discussion of toilet training m a y arise in relation to a deviation from normal or expected behavior, e.g., enuresis or encopresis. Most sources of information available to assist health care providers in developing an approach to toilet training are based on studies performed in middle-class populations. This narrow exposure is augmented by the fact that many physicians who teach in clinic settings practice pediatrics in more affluent suburban communities. The present study was undertaken to determine if mothers at inner city clinics differ from middle-class suburban mothers with private pediatricatians in their attitudes and expectations regarding toilet training. If differences can be demonstrated, this knowledge must be incorporated into training programs which prepare health professionals for roles in parent counseling. In addition, clinicians should have a broad understanding From the Pediatric Ambulatory Care Division, Department of Pediatrics, Columbia University College of Physicians and Surgeons, and Babies Hospital, The Children "s Medical and Surgical Center of New York. *Reprint address: 3975 Broadway, New York, N. Y. 10032.
Vol. 84, No. 1, pp. 148-151
of such cultural and social mores if they are to properly evaluate suspected deviations from normal. METHOD
AND SETTING
An interview questionnaire was designed to elicit maternal expectations and attitudes regarding toilet training. The information collected included: mother's place of birth; sources of information used as a guide in toilet training; opinion regarding the ideal age to initiate bladder and bowel training; opinion about the expected age that toilet training should be completed; and the approach to the child who soils after toilet training has been initiated. One hundered mothers who had brought their
Table I. Major sources of information mothers use as guide in toilet training
Source of information
Physician Family Friends Books Self-taught (common sense)
Pet" cent of clinic mothers
0 45 15 27 13
Per cent of private-patient mothers
7 20 12 32 29
Volume 84 Number 1
Maternal attitudes toward toilet training
149
Table II. Mothers' opinion as to ideal age to initiate toilet training Bladder training
Age (months)
Under 8 8 to 12 13 to 16 17 to 20 21 to 24 25 to 30 31 to 36
Per cent of clinic mothers
Bowel training
Per cent ~f private-practice mothers
Per cent of clinic mothers
Pt~l" t'enl o f
private-practicemothers
Boys
Girls
Boys
Girls
Boys
Girls
Boys
Girls
6 30 27 12 15 10 0
5 30 28 13 14 10 0
0 1 16 30 17 27 9
0 1 16 33 20 25 5
5 22 35 14 14 8 5
4 23 37 13 13 9 1
0 4 16 30 20 22 8
0 4 17 34 20 20 5
children for medical care to the Pediatric Clinic of Columbia-Presbyterian Medical Center were randomly selected for interviewing. This clinic serves an indigent population of Upper Manhattan and the Southeast Bronx. Approximately 50 per cent of the patients are Hispanic American (Puerto Rican, Dominican, Cuban, 9Haitian, Ecuadorian), 30 per cent American black, and 20 per cent white. Cooperation was obtained from all the mothers who were approached. An interpreter assisted in interviewing non-English speaking women. Eighty-nine mothers from two private suburban pediatric practices completed the interview questionnaire with the assistance of office nurses. Each practice consisted of a partnership between two pediatricians, each having teaching responsibilities in the Pediatric Clinic. These practices were located in Connecticut and New Jersey, and served predominantly white middleclass populations. RESULTS Mother's place of birth. Twenty-eight per cent of clinic mothers were foreign born, primarily in Puerto Rico, Cuba, and the West Indies; only 5 per cent of the private-practice mothers were born outside the United States. Thirty per cent of the clinic mothers were born in the South, in contrast to 11 per cent of the privatepractice mothers.
Sources of maternal information about toilet training (Table I). The majority of clinic mothers indicated that family members were the most common sources of information used to guide them in toilet training their children. Mothers from private practices relied most heavily on books and common sense to guide them.
Table III. Mother's opinion as to ideal age toilet training should be completed
Pep"cent of clinic mothers
Per cent of private-practicemothers
Age (years) Boys
1 189 2 289 3 389 4 489 5
Girls
Boys
5
5
0
0
10 36 22 21 4 1 0 1
11 40 19 20 3 1 0 1
3 13 40 30 10 4 0 0
4 12 41 34 6 3 0 0
1
Girls
Neither group of mothers considered physicians to be an important source of information.
Maternal expectations concerning the ideal age to initiate bladder and bowel training. Clinic mothers differed appreciably from private-practice mothers in their opinions concerning the ideal age to initiate toilet training (Table II). Sixty-three per cent of clinic mothers believed that bladder and bowel training should be initiated in boys and girls by 16 months of age, whereas only 17 per cent of the private practice mothers agreed with this opinion. There were no significant differences between the private-practice and clinic mothers in their expectations for boys as opposed to girls.
Maternal expectations concerning the ideal age for
150
Carlson a n d Asnes
The Journal o f Pediatrics January 1974
Table IV. Mother's response to child when soiling occurs
Mother's response
Ignore event Offer encouragement Verbally reprimand Tell child he or she is dirty Spank child Did not answer qoestion
Per cent o f Per cent o f p r i v a t e - p r a c t i c e mothers clinic mothers
15 56 14 4 15 0
17 50 25 8.5 0 5
completion of toilet training. Five per cent of clinic mothers expected their child's toilet training to be completed by 1 year of age and approximately 50 per cent responded that training should be completed by 2 years of age. None of the private practice mothers believed that this goal should be accomplished by 1 year of age and only 16 per cent thought children should have their toilet training completed by 2 years of age. There were no significant differences in maternal expectations for boys as opposed to girls (Table Ill). Response to child when soiling occurs. Mothers were asked what they would do if their child soiled after a program of toilet training had been initiated. Approximately one half of the mothers in each group answered that they would offer the child encouragement. Whereas no private practice mother felt that a child should be Spanked, 15 per cent of the clinic mothers felt that spanking was appropriate. With the exception of the above mentioned difference, mothers from both groups held similar views about the appropriate response to soiling (Table IV). DISCUSSION The child's mastery of toilet training is dependent on the attainment of neuro|ogic and psychologic maturationa! and developmental levels. Brazelton 1 has pointed out that the child must develop local conditioning of reflex sphincter control (9 months), must be able to cooperate voluntarily (12 to 15 months) and that there must be completion of myelinization of pyramidal tracts (12 to 18 months). In addition, and most importantly, the child must have a desire to control the impulse to defecate and urinate. This level of psychologic maturation develops between 18 and 30 months and is significantly affected by parental expectations and attitudes. It is important for the health care provider to understand parental differences in attitudes and expectations
regarding toilet training. When there is a disparity between the child's ability or progress in acquiring desired toilet habits and the parents' expectations, increased potential for the development of behavioral problems exists. 2,3 Conflicts may lead to frustration for both parent and child.and are often destructive to the final goal. An informal survey was conducted among attendings and housestaff serving in this Pediatric Outpatient Department. Almost three quarters of the respondents expressed the opinion that there were no significant differences between clinic mothers and private-practice mothers in their expectations and attitudes in regard to toilet training. The present study demonstrated, however, that significant differences between clinic mothers and private-practice mothers do exist. Possible explanations to account for the differences in attitudes and expectations of these two groups of mothers include: (1) greater economic pressure on clinic mothers to seek employment (having children toilet trained facilitates the finding of adequate care for them while their mothers Work); (2) crowded housing conditions 6f clinic patients, which may be a stimulus to the desire of having children develop earlier independence and self-sufficiency; (3) a less permissive attitude among inner-city mothers than in their middle-class counterparts. In fact, there is a more rigid definition of expected child behavior in many inner-city families. 4 The failure of mothers to recognize physicians as a source of information on toilet training was an unexpected finding and is in contrast with the initial report of Stehbens and Silber. 2 These authors surveyed the attitudes of University of Iowa student families and found that two thirds of the respondents listed the physician as a potential source of advice and guidance. However, Stehbens and Silber have recently completed a followup of the original respondents and found that only 26 per cent actually consulted a physician during the time they were training their children .5 It appears that there is a lack of adequate counseling of clinic mothers in this area of well-baby care. Whereas those mothers in the private practices surveyed maintained reasonable expectations about desired toilet habits many mothers in our clinic expected their children to acquire these habits long before they were physically and emotionally capable of attaining control. Since unrealistic parental expectations may lead to problems in a child's emotional development, the topic of toilet training should be included in discussions on child development with parents. An appreciation and understanding of differences in social mores must be incorporated into the teaching programs of medical personnel.
Volume 84 Number 1
The authors wish to acknowledge the cooperation and interest of Drs. Bertram Grossman, Norman Weinberg, Gilbert Simon, and Preston Zucker, the helpful suggestions of Drs. Susan Gordon, Richard E. Behrman, and Burton Grebin, and secretarial assistance of Ms. Dalia Rosa.
REFERENCES 1. Brazelton, T. B.: A child-oriented approach to toilet training, Pediatrics 29: 121, 1962.
Maternal attitudes toward toilet training
151
2. Stehbens, J. A., and Silber, D. L.: Parental expectations in toilet training, Pediatrics 48: 451, 1971. 3. Huschka, M.: The child's response to coercive toilet training, Psychosom. Med. 2: 301, 1942. 4. Macoby, E., and Gibbs, P.: Methods of child rearing in two social classes, in Martin, W. E. and Stendler, C. B., editors: Readings in child development, New York, 1954, Harcourt, Brace & Company. 5. Silber, D. L.: Personal communication, September 1973.
RichardW. Olmsted, Editor
Maternal expectations and attitudes toward toilet training: A comparison between cl&ic mothers and private practice mothers Mothers at inner city clinics differfrom middle-class suburban mothers with private pediatr&ians in the#" attitudes and expectations regarding toilet training, such as the ideal age to initiate bladder and bowel training, ideal age for completion of toilet training, response to the child who soils after a program Of toilet training has been initiated, and source of i n formation to guide in toilet training. Possible explanations to account for these differences are explored," the implications for training health personnel are discussed.
Susan S. Carlson, M.D., and Russell S. Asnes, M.D.,* New York, N.Y.
PEDIATRIC house officers, nurses, and medical students often learn "acceptable practices" of toilet training from attending pediatricians, pediatric textbooks, and articles on well-baby care. Parents may seek such information from the medical staff or the subject may be explored in the context of providing preventive health care. In addition, a discussion of toilet training m a y arise in relation to a deviation from normal or expected behavior, e.g., enuresis or encopresis. Most sources of information available to assist health care providers in developing an approach to toilet training are based on studies performed in middle-class populations. This narrow exposure is augmented by the fact that many physicians who teach in clinic settings practice pediatrics in more affluent suburban communities. The present study was undertaken to determine if mothers at inner city clinics differ from middle-class suburban mothers with private pediatricatians in their attitudes and expectations regarding toilet training. If differences can be demonstrated, this knowledge must be incorporated into training programs which prepare health professionals for roles in parent counseling. In addition, clinicians should have a broad understanding From the Pediatric Ambulatory Care Division, Department of Pediatrics, Columbia University College of Physicians and Surgeons, and Babies Hospital, The Children "s Medical and Surgical Center of New York. *Reprint address: 3975 Broadway, New York, N. Y. 10032.
Vol. 84, No. 1, pp. 148-151
of such cultural and social mores if they are to properly evaluate suspected deviations from normal. METHOD
AND SETTING
An interview questionnaire was designed to elicit maternal expectations and attitudes regarding toilet training. The information collected included: mother's place of birth; sources of information used as a guide in toilet training; opinion regarding the ideal age to initiate bladder and bowel training; opinion about the expected age that toilet training should be completed; and the approach to the child who soils after toilet training has been initiated. One hundered mothers who had brought their
Table I. Major sources of information mothers use as guide in toilet training
Source of information
Physician Family Friends Books Self-taught (common sense)
Pet" cent of clinic mothers
0 45 15 27 13
Per cent of private-patient mothers
7 20 12 32 29
Volume 84 Number 1
Maternal attitudes toward toilet training
149
Table II. Mothers' opinion as to ideal age to initiate toilet training Bladder training
Age (months)
Under 8 8 to 12 13 to 16 17 to 20 21 to 24 25 to 30 31 to 36
Per cent of clinic mothers
Bowel training
Per cent ~f private-practice mothers
Per cent of clinic mothers
Pt~l" t'enl o f
private-practicemothers
Boys
Girls
Boys
Girls
Boys
Girls
Boys
Girls
6 30 27 12 15 10 0
5 30 28 13 14 10 0
0 1 16 30 17 27 9
0 1 16 33 20 25 5
5 22 35 14 14 8 5
4 23 37 13 13 9 1
0 4 16 30 20 22 8
0 4 17 34 20 20 5
children for medical care to the Pediatric Clinic of Columbia-Presbyterian Medical Center were randomly selected for interviewing. This clinic serves an indigent population of Upper Manhattan and the Southeast Bronx. Approximately 50 per cent of the patients are Hispanic American (Puerto Rican, Dominican, Cuban, 9Haitian, Ecuadorian), 30 per cent American black, and 20 per cent white. Cooperation was obtained from all the mothers who were approached. An interpreter assisted in interviewing non-English speaking women. Eighty-nine mothers from two private suburban pediatric practices completed the interview questionnaire with the assistance of office nurses. Each practice consisted of a partnership between two pediatricians, each having teaching responsibilities in the Pediatric Clinic. These practices were located in Connecticut and New Jersey, and served predominantly white middleclass populations. RESULTS Mother's place of birth. Twenty-eight per cent of clinic mothers were foreign born, primarily in Puerto Rico, Cuba, and the West Indies; only 5 per cent of the private-practice mothers were born outside the United States. Thirty per cent of the clinic mothers were born in the South, in contrast to 11 per cent of the privatepractice mothers.
Sources of maternal information about toilet training (Table I). The majority of clinic mothers indicated that family members were the most common sources of information used to guide them in toilet training their children. Mothers from private practices relied most heavily on books and common sense to guide them.
Table III. Mother's opinion as to ideal age toilet training should be completed
Pep"cent of clinic mothers
Per cent of private-practicemothers
Age (years) Boys
1 189 2 289 3 389 4 489 5
Girls
Boys
5
5
0
0
10 36 22 21 4 1 0 1
11 40 19 20 3 1 0 1
3 13 40 30 10 4 0 0
4 12 41 34 6 3 0 0
1
Girls
Neither group of mothers considered physicians to be an important source of information.
Maternal expectations concerning the ideal age to initiate bladder and bowel training. Clinic mothers differed appreciably from private-practice mothers in their opinions concerning the ideal age to initiate toilet training (Table II). Sixty-three per cent of clinic mothers believed that bladder and bowel training should be initiated in boys and girls by 16 months of age, whereas only 17 per cent of the private practice mothers agreed with this opinion. There were no significant differences between the private-practice and clinic mothers in their expectations for boys as opposed to girls.
Maternal expectations concerning the ideal age for
150
Carlson a n d Asnes
The Journal o f Pediatrics January 1974
Table IV. Mother's response to child when soiling occurs
Mother's response
Ignore event Offer encouragement Verbally reprimand Tell child he or she is dirty Spank child Did not answer qoestion
Per cent o f Per cent o f p r i v a t e - p r a c t i c e mothers clinic mothers
15 56 14 4 15 0
17 50 25 8.5 0 5
completion of toilet training. Five per cent of clinic mothers expected their child's toilet training to be completed by 1 year of age and approximately 50 per cent responded that training should be completed by 2 years of age. None of the private practice mothers believed that this goal should be accomplished by 1 year of age and only 16 per cent thought children should have their toilet training completed by 2 years of age. There were no significant differences in maternal expectations for boys as opposed to girls (Table Ill). Response to child when soiling occurs. Mothers were asked what they would do if their child soiled after a program of toilet training had been initiated. Approximately one half of the mothers in each group answered that they would offer the child encouragement. Whereas no private practice mother felt that a child should be Spanked, 15 per cent of the clinic mothers felt that spanking was appropriate. With the exception of the above mentioned difference, mothers from both groups held similar views about the appropriate response to soiling (Table IV). DISCUSSION The child's mastery of toilet training is dependent on the attainment of neuro|ogic and psychologic maturationa! and developmental levels. Brazelton 1 has pointed out that the child must develop local conditioning of reflex sphincter control (9 months), must be able to cooperate voluntarily (12 to 15 months) and that there must be completion of myelinization of pyramidal tracts (12 to 18 months). In addition, and most importantly, the child must have a desire to control the impulse to defecate and urinate. This level of psychologic maturation develops between 18 and 30 months and is significantly affected by parental expectations and attitudes. It is important for the health care provider to understand parental differences in attitudes and expectations
regarding toilet training. When there is a disparity between the child's ability or progress in acquiring desired toilet habits and the parents' expectations, increased potential for the development of behavioral problems exists. 2,3 Conflicts may lead to frustration for both parent and child.and are often destructive to the final goal. An informal survey was conducted among attendings and housestaff serving in this Pediatric Outpatient Department. Almost three quarters of the respondents expressed the opinion that there were no significant differences between clinic mothers and private-practice mothers in their expectations and attitudes in regard to toilet training. The present study demonstrated, however, that significant differences between clinic mothers and private-practice mothers do exist. Possible explanations to account for the differences in attitudes and expectations of these two groups of mothers include: (1) greater economic pressure on clinic mothers to seek employment (having children toilet trained facilitates the finding of adequate care for them while their mothers Work); (2) crowded housing conditions 6f clinic patients, which may be a stimulus to the desire of having children develop earlier independence and self-sufficiency; (3) a less permissive attitude among inner-city mothers than in their middle-class counterparts. In fact, there is a more rigid definition of expected child behavior in many inner-city families. 4 The failure of mothers to recognize physicians as a source of information on toilet training was an unexpected finding and is in contrast with the initial report of Stehbens and Silber. 2 These authors surveyed the attitudes of University of Iowa student families and found that two thirds of the respondents listed the physician as a potential source of advice and guidance. However, Stehbens and Silber have recently completed a followup of the original respondents and found that only 26 per cent actually consulted a physician during the time they were training their children .5 It appears that there is a lack of adequate counseling of clinic mothers in this area of well-baby care. Whereas those mothers in the private practices surveyed maintained reasonable expectations about desired toilet habits many mothers in our clinic expected their children to acquire these habits long before they were physically and emotionally capable of attaining control. Since unrealistic parental expectations may lead to problems in a child's emotional development, the topic of toilet training should be included in discussions on child development with parents. An appreciation and understanding of differences in social mores must be incorporated into the teaching programs of medical personnel.
Volume 84 Number 1
The authors wish to acknowledge the cooperation and interest of Drs. Bertram Grossman, Norman Weinberg, Gilbert Simon, and Preston Zucker, the helpful suggestions of Drs. Susan Gordon, Richard E. Behrman, and Burton Grebin, and secretarial assistance of Ms. Dalia Rosa.
REFERENCES 1. Brazelton, T. B.: A child-oriented approach to toilet training, Pediatrics 29: 121, 1962.
Maternal attitudes toward toilet training
151
2. Stehbens, J. A., and Silber, D. L.: Parental expectations in toilet training, Pediatrics 48: 451, 1971. 3. Huschka, M.: The child's response to coercive toilet training, Psychosom. Med. 2: 301, 1942. 4. Macoby, E., and Gibbs, P.: Methods of child rearing in two social classes, in Martin, W. E. and Stendler, C. B., editors: Readings in child development, New York, 1954, Harcourt, Brace & Company. 5. Silber, D. L.: Personal communication, September 1973.