Early Childhood Behavioral and Developmental Challenges: Sleeping and Toilet Training - December 2003

At California Pacific’s Child Development Center, we provide evaluation and treatment to children and families with the entire range of developmental and behavioral concerns— from those with profound developmental delay to families seeking advice on more common behavioral issues such as sleep and toilet training. In many cases, providing a family with developmentally appropriate expectations and a few basic tools can help them to navigate through these often challenging early childhood experiences.

Encouraging Good Sleep Habits

Sleep is an active process involving increased activity among many regions of the brain. As a child sleeps, he goes through various physiologic changes needed for his physical and mental health. The required amounts of sleep change as children grow and the frequency of naps diminishes. While the amount of sleep needed to feel refreshed may vary among individuals, general guidelines are:
• Infancy: about 13 hours or more
• Early childhood: 9 – 13 hours
• Children: 10 hours
• Adolescents: 8 – 9 hours
One’s sleep environment also affects the quality of rest. With infants, white noise may be helpful in encouraging encourage sleep. Location, bedding and favorite toys can also affect a child’s ability to fall and stay asleep.

Self-Comforting — Learned self-comforting behaviors are the key to “sleeping through the night.” This way, if a child awakens, he can comfort himself and return to sleep. Children also need to feel safe and have a ritual for winding down before sleep. By following a consistent pre-bedtime pattern, children will learn that bedtime is imminent. This ritual should be simple so that a child could recreate it even if the parent is not present.

Night Wakening and Pediatric Sleep Disorders — Night wakening can be behavioral, emotional or medically based. Again, a consistent bedtime routine helps ensure sounder sleep, although developmental milestones can affect night wakening When children develop object permanency (7 – 9 months), separation anxiety may occur, causing a child to awaken. If this occurs, he should be reassured with minimal interaction. Nightmares can also occur in early childhood and require the same parental input.

In addition to night wakening, common pediatric sleep disorders include bedtime resistance, parasomnias and obstructive sleep apnea. Parasomnias refer to a category of disorders that includes sleepwalking and/or talking, night terrors and confusional partial arousals. Confusional partial arousals usually occur in children ages 3 to 8 when a child gives up a nap, is overtired or falls asleep in a tense state. The arousal begins 1 to 3 hours after sleep and lasts 1 to 10 minutes, with the child having no recall of the event. To prevent such arousals, parents should try to make sure there are positive emotions at sleep onset. Medical problems such as allergy, asthma and other conditions can also disrupt sleep. Loud snoring or pauses in breathing when asleep could indicate sleep apnea and merit a medical evaluation.

Toilet Training

Toilet training (also called toileting) is a multi-step developmental process that requires readiness and voluntary control. When giving advice to parents, it is important to understand different cultural viewpoints. Some suggested children’s books covering toilet training include: Everyone Poops by Taro Gomi and The Gas We Pass by Shinta Cho.

To determine when a child may be ready for toileting, the following are considerations:

  • Child must have interest in the use of the toilet;
  • Motor skill ability must be appropriate—the child needs to ambulate and have the skill to manipulate clothing;
  • Language skills are needed to signal the need to eliminate;
  • Urine training often occurs before bowel training. According to Encounters With Children by Dixon and Stein, “Boys usually train 2 ½ months plus later than girls. First born children are 1.7 months delayed compared to later siblings.”;
  • Stressful family events such as the birth a new sibling, move to a new home and family vacation may delay toilet training;
  • Switch from pull-up diapers to training pants to eliminate the sensory dependence on the pull-up;
  • Child needs to demonstrate control of the anal and urethral sphincters and have periods of being dry and awareness that he/she is eliminating;
  • Have either a child-size potty or toilet seat and a stool for one’s feet to feel secure (beware of automatic flushing toilets).


During or after training, a child may demonstrate significant withholding of stool, which is signified by:
  • Three or more days between bowel movements;
  • Physical difficulty having a bowel movement;
  • Hiding when attempting to have a bowel movement.


If basic measures to treat constipation are not helpful and the primary care physician has already been consulted, then a referral to a Pediatric Gastroenterologist may be necessary.



For further information about California Pacific Medical Center’s Child Development Center, contact:
· Barbara Bennett, M.D. (415) 600-6200
· Suzanne Giraudo, Ed.D. (415) 600-6200
Or visit our Child Development Center Web page.