Toilet training and elimination behaviour

Overview & Definition

Picture a parent who says, “He is four and still wetting — we have tried everything, including smacking.” Your first job is clinical, not moral. Toilet training is the developmental process of learning daytime and night-time continence with support that matches motor, language and social readiness. Elimination behaviour problems include toilet refusal, delayed continence, enuresis and encopresis. [1] [2]

Enuresis is repeated voiding of urine into bed or clothes after chronological age at least 5 years (or equivalent developmental level), with frequency or impairment criteria, not solely explained by a substance or another medical condition. Encopresis is repeated passage of faeces into inappropriate places after age at least 4 years (or developmental equivalent), at least monthly for three months in classic teaching frameworks, not exclusively due to a substance or medical condition except through constipation. [1] [10] [11]

Hold both DSM-style psychiatric nosology and ICCS continence language used in paediatrics and urology. That dual vocabulary is what examiners reward. [2] [3]

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1. [1]Fritz G, Rockney R, et al. Practice parameter for the assessment and treatment of children and adolescents with enuresis J Am Acad Child Adolesc Psychiatry, 2004.PMID 15564822
2. [2]Neveus T, Eggert P, Evans J, et al. Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the International Children's Continence Society J Urol, 2010.PMID 20006865
3. [3]Nevéus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society J Urol, 2006.PMID 16753432
4. [4]Nunes VD, O'Flynn N, Evans J, Sawyer L Management of bedwetting in children and young people: summary of NICE guidance BMJ, 2010.PMID 20980375
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6. [6]Hahn D, et al. Desmopressin for nocturnal enuresis in children Cochrane Database Syst Rev, 2025.PMID 40728007
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9. [9]Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN J Pediatr Gastroenterol Nutr, 2014.PMID 24345831
10. [10]Brazzelli M, Griffiths PV, Cody JD, Tappin D Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children Cochrane Database Syst Rev, 2011.PMID 22161370
11. [11]Loening-Baucke V Functional fecal retention with encopresis in childhood J Pediatr Gastroenterol Nutr, 2004.PMID 14676600
12. [12]Pashankar DS, Bishop WP, Loening-Baucke V Long-term efficacy of polyethylene glycol 3350 for the treatment of chronic constipation in children with and without encopresis Clin Pediatr (Phila), 2003.PMID 14686553
13. [13]Butler RJ Childhood nocturnal enuresis: developing a conceptual framework Clin Psychol Rev, 2004.PMID 15533278
14. [14]Chin X, et al. Desmopressin therapy in children and adults: pharmacological considerations and clinical implications Eur J Clin Pharmacol, 2022.PMID 35199198