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To stop trying to toilet train for a few months then reassess
64%
39/61
To stop trying to toilet train for a year then reassess
7%
4/61
To continue to motivate the child and discipline him if he fails to void appropriately
10%
6/61
To obtain an evaluation from a developmental psychologist
8%
5/61
To stop using positive reinforcement rewards
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Toilet training occurs between 2-4 years of age. If the child is not motivated to stay dry, the best advice is to wait for a few months then reassess. This will give the child and mother a break and allow for both to approach the situation fresh. Regardless, it is normal for children to not use the toilet up until age 5. Toilet training occurs between ages 2 and 4 with 5 being the cutoff age when an inability to use the toilet may be considered a problem. To be ready for toilet training, the child must be aware of bladder filling, able to consciously tighten their external sphincter, has normal bladder growth, and be motivated to stay dry. Further, the child must have met motor milestones and be able to walk to the toilet, sit upright, as well as have met language milestones to communicate the need to use bathroom. The process involves placing the child on a toilet at regular intervals and using positive reinforcement as a reward. If the child is very reluctant, the best strategy is to stop trying to toilet train for a few months and then reassess. Choby and George discuss toilet training. All healthy children are eventually toilet trained and most complete the task without medical intervention. The average age at which training begins has increased over the past several decades from early than 18 months of age to between 21 and 36 months of age. Newer studies suggest no benefit of intensive toilet training before 27 months of age. Girls usually complete training earlier than boys. Numerous toilet-training methods are available. The Brazelton child-oriented approach uses physiologic maturity, ability to understand and respond to external feedback, and internal motivation to assess readiness. Deshpande and Caldwell discuss medical management of nocturnal enuresis. Nocturnal enuresis, or bedwetting, is the most common cause of urinary incontinence in children. Nocturnal enuresis typically presents as failure to become dry at night after successful daytime toilet training.Children with nocturnal enuresis may have excessive nocturnal urine production, poor sleep arousal and/or reduced bladder capacity. Alarm therapy is the recommended first-line therapy. Illustration A is a listing of the major developmental milestones for a pre-school aged child (3 - 5) from the American Academy of Pediatrics. Incorrect Answers: Answers 2: Stopping toilet training for a year would be too long. Such a long break would be unnecessary and would make this child 5 - an age when he should be able to use the toilet. Answer 3: To continue to motivate the child and discipline him if he fails to void appropriately is incorrect only because of the discipline aspect of this answer. Discipline may make the child fear toilet training and be even more hesitant to begin using it potentially worsening the entire process. Answer 4: Evaluation from a developmental psychologist is unnecessary because 1. You are a physician who can evaluate this child's NORMAL development fine on your own (do not refer patients in general) and 2. There is nothing abnormal here that would need a consult. Answer 5: Positive reinforcements should be continued to make the child enjoy the success of using the toilet. To discontinue positive reinforcements may slow the process of toilet training.
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