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Cultural Relativity of Toilet Training Readiness: A

Perspective From East Africa

Marten W. deVries, M.D., and M. Rachel deVries, P.N.P.

From the Departments of Psychiatry and Anthropology, University of Rochester (N. Y.), and the Bureau of
Educational Research, Child Development Research Unit, Nairobi, Kenya

ABSTRACT. Ideas about infant capabilities and toilet preindustrial culture. The cross-cultural compar-
training practice have changed in the United States follow- ison suggests that concepts of toilet training
ing cultural trends and the advice of child care experts.
readiness depend more on social-cultural factors
Anthropologists have shown that a society’s specific infant
training practices are adaptive to survival and cultural than on maturational ones. The influence of
values. The different expectations of infant behavior of the social-cultural factors on infant and caretaker
East African Digo produces a markedly different toilet behavior is discussed.
training approach than the current maturational readiness
method recommended in America. The Digo believe that TOILET TRAINING IN THE UNITED
infants can learn soon after birth and begin motor and toilet STATES
training in the first weeks of life. With a nurturant condi-
honing approach, night and day dryness is accomplished by 5
Infancy and childhood are historically new
or 6 months. The success of early Digo training suggests that concerns in the West. Medieval indifference gave
socioculturai factors are more important determinants of way to the 18th century’s “obsessive love” and
toilet training readiness than is currently thought. Pediatrics concern, which have culminated in today’s
curiosity and scientific investigation. The increase
in child orientation followed trends in moral
education and alterations in social structure and
family life, transforming parental roles from those
of child guardians to those of educators.’
During the last century, American cultural
Social scientists have demonstrated that child attitudes and clinical recommendations guiding
training practices vary across cultures and have parents in the bowel and bladder training of their
changed over time in the United States. Varia- infants have undergone numerous changes. Vacil-
tions in the method and timing of infant training lation between the extremes of rigid scheduling
are related to different expectations of infant and permissive indulgence has occurred. Each
capabilities and performance. These expectations change reflected the mood and pressure of histor-
are embedded in the broad social orientations and ical events and was stimulated by the results of
needs of a population. the latest scientific investigation.
The translation of cultural attitudes into infant
behavior is evident in the bowel and bladder
training methods employed by a population. The
Received September 4, 1976; revision accepted for publica-
Digo people of East Africa have markedly tion January 14, 1977.
different ideas about “toilet training readiness” Supported in part by grant MH16544 from the National
from those held by middle-class Americans and Institute of Mental Health and fellowship funds from the
are successful at this undertaking at a much Department of Psychiatry, University of Rochester.
The statements made and views expressed are solely the
earlier age than the average American family.
responsibility of the authors.
This article will discuss changing trends in ADDRESS FOR REPRINTS: (M.W.D.) Department of
United States toilet training practice and contrast Psychiatry, Medical Center, University of Rochester,
current methods with training observations in a Rochester, NY 19642.

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170 PEDIATRICS Vol. 60 No. 2 August 1977
Stendler,2 Vincent,3 and Wolfenstein, in their TRErnns IN RECOMMENDED INFANT TrtaNINc METHODS

separate reviews of the professional and lay EXTRACTED FROM THREE WOMEN’S MAGAZINES FROM 1890
TO 1948#{176}
literature, mark these changes. From 1890 to
1910, there existed an era of “permissiveness.” In
Mother- Early Ghild-
the 1920s and 1930s, stimulated by the new . Determined Readiness, Oriented
behaviorist school in psychology and the events of Readiness Rigid Readiness,
World War I, permissiveness changed to rigid Environmental 2-3 yr
habit training. Infant Care, published by the U.S. Scheduling
government in 1932, instructed mothers to begin 1890 100% 0% 0%
toilet training immediately after confinement and 1900 78% 22% 0%
finish at 6 to 8 months.6’7 Such early training was
1910 23% 77% 0%
based on new concepts of infant trainability
1920 0% 100% 0%
which proposed to free the mother from the
1930 0% 75% 25%
burden of the infant’s soiling and wetting. Experts
1940 0% 33% 66%
urged coercive methods such as using a “soap
1948 0% 0% 100%
stick” rectal conditioner and stimulating the
buttocks with the “cold rim of a soap dish while #{176}Adapted from Vincent.3
gently rubbing the abdomen.” Absolute regu-
larity was also stressed, and advice to schedule the technology of modern diaper care from the
bowel movements “twice daily, after the morning functional necessity to train the child early. After
and evening bath, not varying the time by as the age of 18 months, mothers were advised to
much as five minutes,” was the rule.8 The infant gradually introduce their infant to the pot. An
was considered a passive recipient of reflex condi- unpressured approach was urged to facilitate the
tioning, and training was reduced to harsh infant’s autonomous control of elimination.
methods that excluded both maternal spontaneity Sphincter control at age 2 to 3 was now consid-
and warmth.9 ered a strictly developmental task. Brazelton’s
During the 1930s, psychoanalytic and develop- recommendations are in accordance with the
mental investigations of the ‘ ‘introduced practice used by pediatricians today.
leniency and a more child-centered approach. Gradually, older times were recommended for
Central nervous system maturational 21 training and less rigid methods were advised.
suggested that it was wrong to stress and “bur- Training habits have followed changes in attitude
den” the young infant with “coercive, prema- about infant capabilities. Although there were
ture” training methods. Such methods even exceptions to the dominant trends, infant care
seemed dangerous, in light of retrospective writers changed opinions in unison, without the
psychoanalytic studies7 indicating a strong rela- benefit of strong, empirical evidence3 (Table).
tionship between coercive methods and later
emotional maladjustment and psychoneurosis. FIELD WORK AND METHODS
Furthermore, evidence that early reflex condi- In 1974, as research associates with the Child
tioning was only temporary’#{176} reinforced the Development Research Unit of the Bureau of
ascendant view that child training should match a Educational Research at the University of
self-regulatory schedule within the child. Empha- Nairobi, Kenya, we carried out field work in East
sis was placed on the child’s cooperation, “readi- Africa. The material presented is part of a three-
ness,” and subsequent active role in training. culture study of infant temperament, using the
Fraiberg’4 states that “in order for a child to Brazelton Neonatal Assessment Scale, the Carey
cooperate in his toilet training, he must be able to, Scale of Infant Temperament, and ethnographic
control his sphincter muscles, he must have the observations and interviews. The three-culture
ability to postpone the urge to defecate, and he study will be reported elsewhere.
must be able to give a signal to be taken to the At Msambweni, approximately 64 km (40
bathroom, or to get there under his own steam. In miles) south of Mombasa, Digo child-rearing
normal child development, these conditions may practice was observed and recorded. We spoke
not be present until 15-18 months or later.” Swahili and lived in a traditional Digo village
In 1962, Brazelton,’5 relying on current phys- home, sharing kitchen and courtyard with
ical and emotional formulations of infant capabil- members of a neighboring extended family. This,
ities, demonstrated the success of a child-oriented in addition to being a pleasant way to live,
approach in a well-educated sample. He facilitated assimilation into village ritual and
concludes that the modern family was freed by daily routine. Participation in village activity

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allowed the gradual growth of friendship, trust, cultivated plots, which, in season, the women
and cooperation which was vital during the often work each day. Life follows the rhythms of the
tedious interviews and observations. Islamic calendar and the ebb and flow of sea, sun,
Initially demographic data-household compo- and rainy season, punctuated by the traditional
sition, census, and mapping-were gathered. activities associated with weddings, birth, death,
Next, the child-training practices and daily and the treatment of illnesses.
routine of the Msambweni community were The traditional Digo matrilineal organization
surveyed. Fifty-six infants and families were has become heavily Islamized, and accordingly,
tested and interviewed after the basic data were all but casual social life is sexually segregated.
collected. Information was gathered by trained Males and females do not eat, work, or worship
local mothers, teenage research assistants, and us. together. Men are absent from the homestead
In addition to the instruments used in the larger most of the day, fishing, doing chores, performing
study, information was gathered using maternal wage labor, or praying in the mosque with other
expectation and performance questionnaires, as men.
well as an extended child-training interview Beginning at 6 AM, women’s work paces village
adapted from Ainsworth.’6 Direct observation of activity. They are involved in continual social
the family and of mother-infant interaction was interaction as they work at the well, shamba,
also an integral part of the research. around the cooking fire, or in the forced leisure of
After the initial survey, the results of cleanli- the tropical afternoon. The morning’s fish catch
ness training questions proved interesting. Thirty and an assortment of seasonal fruits and vegeta-
of 34 mothers in a random sample of households bles are sold at a daily market. The day ends at
containing 3- to 12-month-old infants stated that sunset with the warm and smoky ambience of the
they initiated bowel and bladder training during evening meal. Night is disturbed only by a call
the first few weeks of life and expected or had from the mosque.
accomplished reasonable night and day dryness The Digo baby’s first two months are spent in
by 4 to 6 months. almost constant physical contact with the mother,
Interviews and observations with mothers in her arms or strapped to her back for comfort,
currently in different phases of infant training sleep, and maternal convenience. After confine-
followed. In addition, 16 infants were observed ment, he accompanies her throughout the daily
over five months, noting among other parameters routine, on all chores and social outings. Between
their sphincter mastery. The complexity and time 2 and 3 months, other family members gradually
limitations of the total project did not allow for a increase their caretaking responsibility as the
full quantitative appraisal of this training method. mother returns fully to her chores. By the middle
The observations and maternal reports, however, of the third month, the infant is actively being
are uniquely interesting. They are a specific cared for by family members of all ages, except
example of how a markedly different idea about the father. Mothers stated that a baby is “ready to
infant capabilities and approach to toilet training learn” soon after birth, and expect a high degree
can be as successful as methods recommended by of motor and social achievement at 3 to 5 months.
leading child specialists in this country. Training toward motor and social competence
continues throughout the first year with the goal
of producing a relatively self-sufficient infant who
The approximately 110,000 Digo are Muslim is able to be left in the care of others, freeing
Bantu-speaking people inhabiting the wooded- mother for her work. After one year the infant is
grassland, coastal plain extending south along the expected to walk, to control elimination, and to
Indian Ocean from Mombasa into Tanzania. Digo be able to verbalize his simple needs. Until age 5
men and women are farmers who have added to 6, both boys and girls stay about the homestead
fishing, wage-labor in Mombasa, and work on and help with the home activities of child care,
coconut plantations to their economy.’7 They live food preparation, and repairs. After this period,
in extended family clusters and inhabit large tasks become more sexually stereotyped; boys
rectangular dirt houses with grass roofs. These are tend domestic animals and gather coconuts while
generally organized into villages with populations girls take on increased responsibility for domestic
up to 3,000. A typical homestead houses six to ten tasks. Teenagers, if possible, attend school. At this
adults and children and consists of a large main time, full adult activity is initiated, marked by the
house and an adjacent enclosed courtyard in cultural ideals of group sharing, eloquence, and
which most of the domestic and social activities self-restraint.
take place. Villages are surrounded by “shamba,” The broad features of Digo infant-rearing prac-

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4. ,(‘

FIG. 1. Standard urination training positions. Infant is 90 days old. Left, Training position during “shuus” sound. Center, Infant
response. Right, A task well done.

tice, then, are a multiple caretaking system, much on the ground outside, with her legs straight out
physical contact, unscheduled sleep times, and in front of her (Fig. 1). The infant is placed
demand breast feeding. Digo mothers monitor between the mother’s legs, facing away from her,
infant behavior closely and feel that responding to in a sitting position, supported by the mother’s
a newborn’s cry or behavior is a way of teaching body. The mother then makes a “shuns” noise
him. They thereby reinforce infant responses to that the infant learns to associate with voiding.
visceral sensation, hunger, attachment, needs, and This is done many times during the day and at
illness into a vocabulary of signals used in early night. When the infant voids as the “shutis” sound
training. The Digo understand infancy as is made, he is rewarded for his behavior by
patterned with optimal development and training feeding, close contact, or other pleasurable activ-
periods, occurring early. ity. Gradually, the infant is expected to become
more articulate in communicating his needs or by
climbing to the appropriate elimination position.
He is expected to urinate in position and on
Since the mother spends most of her time with command at least by 4 to 5 months.
the infant during the first months, it is an ideal For bowel movements, the procedure is similar,
time to accomplish training. Bowel and bladder the positioning different. The mother again sits on
training are initiated simultaneously and extreme- the ground or floor but with her knees bent. The
ly early, at about 2 to 3 weeks of age. The mother infant sits facing her, supported on the lower
takes a teaching role and assumes all responsi- parts of her legs, with his legs over hers and
bility in the initial phase of the training process. leaning slightly forward, the support of her feet
She places the infant in a special training position providing a kind of “potty” (Fig. 2). Here the
outside the house, at first at times when she senses mother does not make noises as in bladder train-
that the infant needs to eliminate (after feeding, ing; the stimulus to eliminate seems positionally
when waking from naps, etc.), with the idea that related. Again the infant is rewarded by pleasur-
he will soon learn to let her know more indepen- able activity if he moves his bowels. If he does not
dently. eliminate, he is matter-of-factly returned to his
At about 2 to 3 weeks of age, the mother begins previous activity or position.
by putting the infant in a position assumed to In both bladder and bowel training, other
facilitate elimination. For voiding, the mother sits siblings or neighbors are frequently present and

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. I
t ..
‘ -‘ .‘

. .;

Fic, 2. Bowel training position. Left and center, Slight variant of normal position. Right, Mother and 4-month-old child in more
traditional stance.

social interaction is not curtailed. It is not With ambulation, he fully enters the family
regarded as private or unclean activity but is domain. He now spends time almost exclusively
rather a relaxed and normal daily part of infant with older siblings or a mother’s helper who is
care. also responsible for other chores. He is now
The mothers reported that they learn by a expected to eliminate away from the living area
vigilant reading of the infant’s movements and of the house. Often there is a trash pit near the
skin and muscle tension to distinguish a language house that the child uses until he learns by
of grimaces, grunts, and cries. Specific pushes and imitation to use the pit-latrine adjacent to the
shoves alert the mother when the infant is tied on house. At a year, if he eliminates in the house or in
the back. At these times, she may occasionally the courtyard, he is at first warned and then
stimulate a sphincter reflex with a gentle pat to physically punished.
the rear. Although an organized inquiry into the later
By being positioned at these appropriate times, effectiveness of training was not possible, inter-
the baby is assumed to associate elimination with views and casual observations of 1- and 2-year-
position and visceral sensation. In the consistent olds suggest that regressions and slips are rare.
context of his mother’s body, the infant is said to The social pressure of older siblings who partici-
l)e learning to signal his needs. When training is pated in the early training, and who were trained
reasonably underwav at 3 to 5 months, helpers themselves, probably guides control during the
who have also learned the infant’s elimination potential messy period’5 in the second year.
signals participate in further training. Young girls The initial survey, with 30 out of 34 mothers
aged 5 to 12 years now assume the training reporting toilet training success at approximately
positions at the appropriate times. They are in 4 to 6 months, was verified by further questioning
turn scolded or occasionally physically punished and when possible with observations. Of the 16
if they are not responsive or sensitive to the infants followed up to age 5 months, ten mothers
infant’s needs. While attachment of the infant to reported daytime dryness and rare night slips. Of
the girl caretaker may at times exceed that to the the others, two had diarrhea, three of the youn-
mother, it is also true that occasionally soiling will gest (4 months) were “improving,” and girl twins
increase during these caretaker switches. ( to be reported elsewhere) were not yet trained.
Throughout the first year, occasional night and In general, variations and delays prolonging
day slips are expected and handled casually, cleanliness training within the total sample were
perhaps only with an exclamation of surprise, related to negative maternal or caretaker atti-
after which the mother or caretaker cleans up the tudes and sickness, to infant diarrheal diseases,
excrenient im m ediately Expectations . again and to some extent his individual characteristics.
change at a year of age, when the infant begins to It was not possible to assess how the prolonged
walk and becomes increasingly independent. training in these situations affected outcome.
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older because at that time the child is physiologi-
cally and psychologically ready. These develop-
As the above example suggests and other mental coordinates are coupled with parental
studies have indicated,’6”8 ideas about the readiness and lend themselves to a relatively
optimal time for bowel and bladder training vary trouble-free training system. This mutual readi-
among contemporary cultures as much as they ness may similarly be seen at work among the
have changed over time in the United States. Digo. There, parental readiness is governed by
Differences in the severity of training style, the the increased time available to mother during
degree of indulgence of infant needs, and the age early infancy, a concept of the infant’s sequential
of training onseV9 occur between most industrial maturation with early optimal times for training,
and preindustrial groups. and a push for an autonomous child much sooner
How may the influences creating variations in than in our society.
training technique and style be examined in a Digo early bowel and bladder training differs
clinically useful way? from early training in the United States during
Every culture has rationales for their infant the 1920s in two important ways. The Digo view
training behavior. A network of complexly their infants as active, not passive, participants.
related factors2 shapes a culture’s ideas of what Second, Digo training style is less severe and more
infants are and what they can do. Training indulgent of infant needs. In contrast to “burden-
behavior is carried out in light of these expecta- ing” the infant with conditioning techniques that
tions. Simply, social organization is strongly disregard his emotional needs, the Digo practice
influenced by changes in the physical and tech- is part of a series of reciprocal cue and rule
nological environment. It is an adaptive system.’9 learning,28 in essence, the growing acquaintance
Infant training is one of these adaptations.2’ of mother and child,29 not a fixed regimen.
Factors such as living conditions, projected desir- Digo mothers say that they influence infant
able traits, needs of daily routine, maternal and growth by matching their training technique to
food availability, etc., condition parental goals the infant’s physical capacities and his manifest
and training methods.22 A cultural “blueprint”2’ ability to learn. They slowly time toilet posi-
for rearing behavior develops which influences tioning to the infants rudimentary physical
and ascribes meaning to the interactions between signals. Their responsiveness to infant signals and
caretakers and infants. Infant responses to help with the regulation of the infant’s state3#{176}in
training techniques in turn feed back on and turn facilitates the infant’s further signaling
reinforce or modify cultural expectations. efforts.3’ Training appears well accepted and
Individual rearing styles are not culturally seemingly becomes self-motivated, as demon-
uniform, however. They are affected by the strated by the infant’s tendency, when his motor
infant’s name, birth order, the history of previous abilities allow, to take the initiative himself in
siblings,23’24 seasonal variations in family rou- finding and assuming the position to excrete
tine,’8 as well as individual infant differences.25 waste. After excretion it is not uncommon to
Caretakers also are not the mere transmitters of observe the infant smiling, affectionately, “almost
cultural rearing goals; they have personal histo- proudly,” at the mother (Fig. 1, right).
ries and characteristics26 as do their infants.27 It is possible that developmental precocity of
Since individual variations and shared rearing African infants32 plays a role in early training. The
style exist within each cultural group, it may be observed technique could be adaptive to the Digo
useful to view mothers as having dual roles. newborn’s advanced neurologic and cognitive
Analytically speaking, she acts as both a personal repertoire. Methodologies seeking genetic deter-
and socializing agent. Her infant care is minants of behavior across cultures may be avail-
influenced by her personal needs as well as able in the future, but only scattered and contra-
cultural child-rearing ideas. As a socializing agent dictory evidence3’ exists to date. Studies that do
her goals and interactions with her infant are suggest precocious development35 stress the
guided by larger cultural adaptations. In this importance of situational, socioeconomic, and
model, infant training interactions are attuned to infant learning factors. At present, no clear
personal and environmental pressures as well as evidence exists that genetically accelerated devel-
cultural values. opment accounts in any major way for the effec-
tiveness of early training.
There is evidence suggesting that early exercise
In the United States with modern diaper care of the walking reflex leads to its maintenance and
Brazelton and others’4”5 discuss the appropriate- subsequent earlier walking alone.36 Zelazo and
ness of training the child at about 18 months or Zelazo suggest that there is an optimal time, the
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first eight weeks, during which exercise can responsive to these factors. Contrary to the
facilitate a transition from reflex to instrumental current view that all early training is ineffective
action. If this hypothesis is correct, Digo early and/or coercive, maturational timing and “readi-
training and concept of optimal time may simi- ness” ideas are related to success only in the way
larly exercise the urinary and anal sphincteric they fit into the total rearing milieu. Readiness is
reflexes to early acquisition of control. a consequence of a group or family’s conceptual
In addition, environmental factors play a role. and functional ability to carry out a nurturant
The alkalinity of coastal soil which inhibits the conditioning technique, and is probably limited
putrification of urine may make this method more only by the individual infant’s biologic con-
acceptable. The relatively uncomplicated living straints.37
environment facilitates early training by necessi- Early training among the Digo and other East
tating only training to place-”outside the house” African people,38 as well as other accumulating
and “not in the bed”-instead of to a vessel or evidence on early infant learning,3” imply that
toilet, requiring larger infant adaptations. It also infancy can be a profound and successful training
does not require the constant unbuttoning and period amenable to stimulating and nurturant
unzipping of Western clothing. interactive approaches. A potentially useful time
In summary, within the Digo environment, the for cognitive development may be neglected by
early, consistent, and nurturant training interac- our cultural view of infancy.
tions achieve the cultural requirement of a rela- In light of the multiple infant training possibil-
tively self-sufficient infant able to be left in the ities across cultures and over time in the United
care of others, freeing the mother for her work. States, it behooves the pediatrician to be flexible
If we examine Brazelton’s popular approach’5 in family guidance. Context and setting as well as
again, taking mutual readiness and cultural infant needs should be considered. By dogmati-
factors more fully into account, a different view cally advocating a seemingly scientific approach
of its clinical significance becomes apparent. while ignoring the potential diversity and effect
Brazelton implies the importance of cultural and of maternal and family expectation, the clinician
technological contexts but based his child- may, in fact, thwart the training goals.
oriented approach firmly on “maturational readi- Clinicians, especially those with heterogeneous
ness.” In the ongoing context of his clinical care, racial and ethnic practices, should inquire about
however, he was able to set and support concepts existing ideas of childhood and take them into
and expectations of infant capabilities as well as account. Further research into the effects of
provide related, concrete training methods. His family and cultural environments on rearing
study then demonstrates the strength of clinically modalities, expectations, and infant behavior
reinforcing parental expectations much as Digo should yield valuable therapeutic approaches.
culture supports and makes successful its infant
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Cultural Relativity of Toilet Training Readiness: A Perspective From East Africa
Marten W. deVries and M. Rachel deVries
Pediatrics 1977;60;170

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Cultural Relativity of Toilet Training Readiness: A Perspective From East Africa
Marten W. deVries and M. Rachel deVries
Pediatrics 1977;60;170

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since 1948. Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright © 1977 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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