Helping Students Develop Daily Living Skills: Feeding, Toileting, Grooming, and Dressing

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Helping Students Develop Daily Living Skills
Feeding, Toileting, Grooming, and Dressing

• Presented By
• Andrea Merlo, OTR/L
• TherAbilities Pediatric Therapy Services
• April 8, 2006

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Paraeducator Development Plan Menu(to be used in
conjunction with Paraeducators Personal
Development Plan)
Directions This menu is a tool for you to use as
you progress through the Paraeducator Course.
Whenever you come across topics about which you
would like more information, place a checkmark
next to the topic and indicate in the Notes
column any specifics (for example, in 1 indicate
which disability). For each topic checked make an
entry in the Paraeducator Personal Development
Plan.
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Paraeducator Development Plan
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District, IU, Preschool Agency Policy

• Your local district, IU, preschool or employing
  agencys policies regarding paraeducator job
  descriptions, duties, and responsibilities
  provide the final word!

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Agenda for today

• Learning Objectives
• Daily Living Skills defined
• Daily Living Skills in the school environment
• Factors influencing student attainment of daily
  living skills
• Dressing, Hygiene, Grooming, Feeding, Toileting
• Techniques for teaching skills
• The importance of collaboration
• Time for Questions

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Learning Objectives

• Identify the functional daily living skills
  addressed in most educational environments
• Recognize the essential sequence of abilities
  associated with hygiene, grooming, dressing,
  feeding, and bathrooming/toileting skills
• Describe effective methods for developing self
  help skills in children
• Collaborate with the educational team of
  professionals involved in teaching children daily
  life skills

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Activities of Daily Living are the basic tasks
of everyday life
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Three Domains of Daily Living Skills

• Self Maintenance (personal tasks of self care,
  social interaction, communications, mobility)
• Work and Productivity (maintaining the home,
  employment, education, volunteerism)
• Play and Leisure (time for amusement, relaxation,
  recreation, enjoyment)

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Self maintenance activities take up 10 -15 of
our time daily (that time is slightly higher for
those people with disabilities)
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Our focus for today

• Eating
• Bathrooming/Toileting
• Dressing
• Hygiene
• Grooming

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Eating at School

• Finger feeding
• Oral Motor abilities (bite, chew, food textures)
• Cup drinking
• Utensil Usage (spoon, fork, knife)
• Managing the lunch line
• Opening containers (milk carton, fruit
  containers, chip bags)
• Drinking from a water fountain

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Toileting at School

• Sensory Awareness
• Communicating the need to void
• Postural stability
• Clothing management
• Hygiene skills
• Transfers/Mobility
• Use of adaptive devices (ex. catheter)
• Feminine hygiene

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Dressing Clothing Management at School

• Taking on and off coat
• Gloves / hat
• Clothing management during toileting tasks
• Dressing for gym class
• Shoe tying
• Managing fasteners on book bags

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Grooming at School

• Combing Hair
• Washing face
• Washing Hands
• Blowing / Wiping Nose
• Aspects of Toileting
• Brushing Teeth
• Napkin usage

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Factors Influencing Levels of Independence

• Students personal motivation
• Cognitive, Motor, and Sensory abilities
• Developmental Readiness
• Physical Status or Conditions
• Family Expectations / Priorities
• Opportunities to practice and generalize skills
  on a routine basis at school and home

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Many of the children we work with do not follow
the expected developmental sequences for these
skills, hence these levels can only serve as
guides.
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Sensory Preparation

• Tactile considerations
• Massage
• Lotion
• Physical Play
• Heavy Work Activities

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Developmental Self-Feeding SummaryHandout A
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Oral Stimulation is Foundational to Childs Sense
of Self

• Map of face, mouth, head in relation to rest of
  body
• Oral stimulation facilitates alertness and self
  regulation
• Smell facilitates alertness and enhances memory
• Eating may help with speech development

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Preparing the Child

• Posture
• Communication
• Sensory
• Oral-Motor
• Consistency

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Positioning

• Aligns to preserve open airways
• Enhances breathing
• Facilitates good eating sequence
• Facilitates coordination of swallowing

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Positioning.

• Hastens good digestion
• Decreases likelihood of reflux or constipation
• Improves social interactions
• Promotes communication

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Pelvic Position
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Posture
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Posture Feeder and Child
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Sound Equipment
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Common Eating Problems

• Retraction Jaw/Cheek/Lip/Tongue
• Inadequate Lip Closure
• Tongue Protrusion
• Tongue Thrusting
• Tonic Bite Reflex
• Jaw Thrusting
• Jaw Clenching

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Abnormal Sensory Reactions

• Refusing Food
• Picky eating (prefers soft foods that dissolve
  easily with saliva in mouth)
• Gagging
• Vomiting
• Stuffing Food into Mouth
• Sucking Food
• Limited Textures/Diet

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Sensory Influences

• Thin vs. Thick Liquids
• Texture
• Temperature
• Wet vs. Dry Foods
• Food Tastes
• Visual Appearance
• Smell

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Behaviors

• Food refusal
• Food selectivity
• Mealtime tantrums
• Excessive meal duration
• Rumination
• Pica

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Gastroesophageal Reflux

• Frequent return of stomach contents into
  esophagus
• Anatomical and Physiological factors
• GER may be associated with vomiting but is also
  gastric contents to any level of esophagus
• Difficult to establish and diagnose
• Links to apnea, respiratory arrest, SIDS

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Aspiration

• Accidental inhaling of food into airway
• Can occur during swallow, with a depressed or
  absent swallow, or with reflux
• Aspiration pneumonia - an inflammation of the
  lungs and bronchial tubes caused by inhaling
  foreign material, usually food, drink, vomit, or
  secretions from the mouth into the lungs. This
  may progress to form a collection of pus in the
  lungs (lung abscess).

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Allergies

• Allergies and nutrition
• Anaphylaxis is an allergic reaction that can be
  fatal within minutes, either through swelling
  that shuts off airways or through a dramatic drop
  in blood pressure.

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Communication

• Developing a trusting relationship with the
  feeder
• Reading childs cues communication attempts
• Acknowledging childs feelings
• Giving child some control over feedings

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Feeders approach may cause behavioral problems
if.

• Feeder is too intrusive for childs skills or
  personality
• Feeder uses forced feedings
• Excessive anxiety is present at meals
• Childs behaviors are not properly managed

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Making Mealtimes Enjoyable

• Coordinate presentation of food with childs
  breathing and movement
• Give child clear view of food with proper
  positioning and lighting
• Use smooth and predictable pace
• Feeder uses ready signals
• Wait, observe and reinforce signals
• Minimize distractions and interruptions

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Making Mealtimes Social

• Determine what levels of social interaction will
  facilitate/motivate childs feeding
• Include peer/s for appropriate portions of
  feeding
• Use specific techniques in effective ways (i.e..
  before going to cafeteria snack time)
• Use cafeteria time for socializing before or
  after meals

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Feeding Methods

• Breast
• Bottle
• NG / G-Tube
• Spoon
• Self-Feeding Finger, Utensil
• Cup
• Straw

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Why Toileting?

• Self Esteem
• Social Significance
• Inclusion in community activities
• Vocational Implications
• Life after School

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Developmental Toileting Considerations

• Toileting consists of training the sphincter
  reflexes and developing the volitional holding of
  urine and feces
• This typically happens after a child begins
  standing and walking
• This action is reflexive until the spinal tract
  is myelinated to a level for bowel and bladder
  control
• Usually bladder control is achieved before bowel

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Developmental Toileting Considerations

• At 10 months, a child indicates discomfort (need
  to void) mainly through facial expressions
• At 14 months, a child may use an action or
  gesture
• Daytime bowel and bladder control usually occurs
  by 30 months
• Night time bladder control may not develop until
  5 to 6 years of age due to physical factors
• Girls tend to be trained 2.46 months earlier than
  boys
• (Pratt Allen 1989)

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Readiness

• Chronological age
• Mental / Developmental Age
• Does the child notice or sense when diapers or
  pants are soiled?
• Does the child exhibit interest in toileting
  behaviors?
• Are there medical considerations or conditions
  that would impede toileting success?

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Strategies

• Use toilet at regularly scheduled times
• Develop a toilet routine
• Use of visual schedule to support routine
• Use specific concrete steps / cues
• Charting of responses
• Address waking hours first
• Provide all necessary materials within easy reach
• Use clothing that promotes independence
• Use of Social Stories

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• Other considerations
• Communication
• Positioning Special Equipment /
  Seating Supporting FeetMonitoring fluid
  intake
• Boys to stand or sit ???

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Strategies to Encourage Relaxation

• Turning on water to help kids urinate
• Playing soft music
• Providing books or magazines
• Reducing distractions
• Dimming lights if possible
• Providing some privacy where possible

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Potential Pitfalls

• Fear of the bathroom, toilet, or flushing
• Sensory issues (texture soap, toilet paper,
  toilet seat)
• Postural security when seated
• Bowel control anxiety
• Water play
• Familiar vs Unfamiliar environments

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Fundamental skills underlying dressing

• Awareness of body scheme
• Kinesthetic awareness
• Tactile processing
• Visual Skills (discrimination, spatial awareness)
• Fine and Gross motor skills (eye-hand
  coordination, refined dexterity, balance
  equilibrium

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Developmental Pre-Dressing Checklist

• Handout B

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Dressing tips

• Make dressing tasks routine (daily practice is a
  must)
• Present the task in a systematic sequence of
  steps
• Remember motorically, it is easier to undress
  than to dress
• Consider positioning to optimize task performance
• Use of visuals

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Hygiene Grooming Skills

• Hand/Finger Dexterity
• Bilateral Skills
• Tool Usage
• Motor planning
• Kinesthetic and tactile sensations
• Most children have the motor skills to complete
  the actual grooming or hygiene task, but not the
  awareness and responsibility to perform them.

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Developmental Sequence for Independent
Hygiene/Grooming Skills

• Turns faucets on/off - 3 years of age
• Wash/dry hands/face 4 years, 9 months
• Bathing 8 years
• Deodorant 12 years
• Cares for teeth 4 years, 9 months
• Cares for nose 6 years
• Cares for hair 7 years, 6 months
• Cares for nails - 8 years
• Feminine hygiene Puberty
• (Pratt Allen 1989)

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General Techniques for Daily Living Skills at
School

• Standard teaching approach/sequence
• Remediation
• Compensatory Approaches
• Adapting task or approach
• Use of Assistive Technology
• Consistent Motivation and Reinforcement

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Techniques

• Backward Chaining
• Trainer prompts student through entire process
  leaving the last step for the student to perform.
  Once that step is mastered, the student adds
  steps from the end of the process to the
  beginning until he/she can perform the whole task.

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Techniques

• Forward Chaining
• Child is taught the first step in the sequence
  of task. After mastery of the first step,
  subsequent steps are presented in order until the
  child can perform the whole task.

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Techniques

• Systematic Cueing
• Visual or Gestural prompting
• Visual schedules
• Video Taping
• Use of mirrors
• Physical prompting
• Hand-Over-Hand assistance

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Team Members

• Parents/Guardians
• Teachers
• Occupational Therapist
• Speech Therapist
• Physical Therapist
• Nurse
• Educational Paraprofessionals

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It is important to remember that all individuals
working with a student on the same tasks should
be consistent in their approaches, cues, and
language to best promote skill development.
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Learning Objectives

• Identify the functional daily living skills
  addressed in most educational environments
• Recognize the essential sequence of abilities
  associated with hygiene, grooming, dressing,
  feeding, and bathrooming/toileting skills
• Describe effective methods for developing self
  help skills in children
• Collaborate with the educational team of
  professionals involved in teaching children daily
  life skills

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Upcoming Videoconferences

• April 26, 2006
• Legal Issues in Special Education What
  Paraeducators Need to Know
• May 17, 2006
• The Competent Learner Model

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Upcoming Regional Training Sessions

• August Live Trainings
• August 9-10- King of Prussia
• August 15-16 Pittsburgh
• August 17-18- Harrisburg

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Wrap Up

• Complete the Paraeducator Development Plan
• Complete Evaluation Form