Self care - children and young people occupational therapy service in Enfield

Morning Routine

It is important for a child to have an established morning routine that is consistent. This supports their understanding of what is expected of them and what will happen next. Checklists (either visual or written) can be useful to guide a child through the steps of the routine.

When using a Visual/Written Schedule it is recommended you:

• Place the visual in a clear place where the child can easily see it and refer back to. You may prefer to have a visual that can move around the house with you during the morning routine.
• Refer your child back to the visual upon completion of each step or if they become distracted
• Reminders and timers can be used to help move through each step i.e. 3 minute timer for brushing teeth before moving onto the next step.

Examples of visuals:

When selecting and building a visual for your child it is important to consider their current communication style and interests (Can they read and are motivated by words? Do they respond better to pictures? Will they engage in ticking off a step or prefer to cover/move the task to a finished spot?)

Below are some examples of different visual schedules you can use with your child to support their engagement in the morning routine. These are just examples, when you build/use a morning routine with your child include the step/tasks that are a part of the morning routine in your household. Further templates can be found on twinkl https://www.twinkl.co.uk/search?q=morning+routine&c=244&r=parent  

See the following examples of morning routine visuals that you can create and personalize for your child. 

 

 

You can also use a written checklist for your child to complete and tick as they go through each step in the morning. For example:

 

 

 

It is important for a child to have an established evening routine that is consistent. Visual checklists can be useful to guide a child through each steps of the routine. Placing the visual in a clear place means it is easier for a child to follow and each stage can be ticked off. Reminders or timers on a phone can be helpful to following routines in a timely manner.

Toileting

Toilet training can be a difficult process for several reasons:

• It can be difficult for the child to understand why they are sitting on the toilet and what they are expected to do.  It is often by first chance that children begin to make the connection between the toilet and their needs.
• A child may have difficulty generalising skills; the nappy is what they have always used, and they see no need to use the toilet since they have no idea what it is for.
• Some children may find the big hole of the toilet frightening; others may find the cold seat upsetting. 
• A child may not be able to make the connection between a wet or soiled nappy and discomfort.

Basic stages in toilet training:

• Begin when you would start to toilet training a typically-developing child, at 2 to 3 years old.
• Jogging pants or track suit bottoms are ideal as they are easy for the children to pull up and down.
• Start putting pants / knickers over the nappy when you dress your child each day.
• Buy a step and children’s toilet seat to ensure your child is comfortable when sitting on the toilet and their feet are well supported. Knees should be slightly above the hips for an ideal position.
• It is better to start with the toilet straight away than using a potty. If you use a potty first then there is a chance that you will have to support your child to transition to a toilet.
• Change the child’s nappy in the toilet so that s/he learns that the toilet is the room where these activities take place.
• Choose words or symbols and be consistent, e.g. “wee”, “wee-wee”, “peepee”, “pooh” etc

                                                

  

• Give lots of praises and celebrate little wins. Even if there are no results, it is important to continue practising consistently to help your child understand what is expected and feel motivated to keep trying.
• It is important to be consistent with the toilet training routine in all settings, discuss your plan with your child’s nursery/school including any visuals, verbal prompts and praises/rewards you are using.
• You can provide your child with hand over hand support to guide them through all the steps for example to flush the toilet or getting dressed.
• Remember, all of these steps take time and consistency is key.

For more information see the following links

Bladder and Bowel UK : Bladder & Bowel UK home page - Bladder & Bowel UK (bbuk.org.uk)

ERIC: Home - ERIC

Teeth Cleaning

It is important to brush twice daily for good oral hygiene.

Start by:

• Placing visual by the sink that breaks the task into steps for the child to follow
• Encourage the child to brush their teeth while looking in a mirror so they can watch what they are doing.
• Download a teeth brushing app onto a smart phone or tablet that the child can watch while they brush their teeth. They are helpful when learning the steps to teeth brushing and encourage them to brush for sufficient time in a fun way. Initially the child will require adult supervision to ensure that they do not become distracted by the ipad and attempt to use it to play games on rather than use the teeth brushing app.
• Place a timer on that ensures the child brushes for the full 2 minutes
• Use plaque reveal tablets. The child chews on them and the purple will stick to all the plaque and they would then have to brush until all the purple is gone.
• Make teeth brushing a group activity. Your child will learn by observing so practising this together will be helpful.

Getting dressed is a task that children and young people carry out daily, which involves fine and gross motor skills, organisation, sequencing, balance, and coordination skills.  Below shoes the progression of dressing skills, children will first learn and develop skills at undressing before beginning to dress items of clothing.

Dressing Development

First Stage	Beginning to push arms through sleeves of a shirt Take off socks, shoes, and hat Push legs through underwear, trousers or leggings Pull underwear or trousers up Begin to pull down own underwear or trousers
Second Stage	Take off own coat Remove loose elastic waist band pants or trousers Put on a simple T-shirt with no fasteners (does not button at this age) Unzip a zip Unbutton large buttons Starting to undress tops and underwear
Third Stage	Undress tops Dress self in t-shirts or sweaters with some assistance Put on trousers with assistance for zips/buttons Able to fasten large buttons independently. Pull up zips on jacket once it is started Put on shoes and socks (not yet able to tie shoes)
Fourth Stage	Able to dress and undress most clothing items Able or beginning to tie shoelaces

A strategy for teaching dressing is using ‘backward chaining’ strategies.

Backward chaining is more likely to guarantee success because you start teaching a skill near the completion of the task. Break the task of dressing down into small, manageable steps. Then teach your child to help with the last step. Continue with this until they are able to complete this successfully. Gradually work backwards, asking your child to do one more step at a time.  Much like moving the starting line of a race further from the finishing line, until you reach the beginning.

General Tips:

• Undressing is an easier skill to learn than dressing.
• Looser fitting clothing is easier to manage than tight fitting clothing.
• Try to be consistent with the dressing process. E.g. start with the same side of the body each time.
• Try to work on dressing at the same time each day and in the same location. 
• Leave extra time so your child does not feel rushed. So start practicing dressing at times in the day where you may have additional time (for example, undressing for bath time or in the afternoon)
• Minimise distractions and interruptions.
• Try practicing shorts before practicing trousers.
• Begin with short-sleeved shirts before long sleeved, as they are easier to manage.
• Once your child is confident with pulling on/off clothing, progress to teaching fastenings such as zips/buttons/laces.
• As your child becomes more familiar with each step of a task, gradually reduce your assistance. Let your child take more and more responsibility.
• You can use visuals to support your child’s ability to break down each task into smaller steps and support sequencing the order clothes get placed on the body. Examples are below.

AND REMEMBER…end each session with a success and praise your child’s efforts!

Shoelaces:

Learning to tie shoelaces can be a complex task requiring lots of sequencing, fine motor skills and persistence. When starting to teach shoelaces to your child ensure you have lots of time and you can break down each step slowly showing your child each movement and step.

There are multiple ways to tie shoelaces, if your child is struggling with one method you can try another to see if this is easier for them. Two of the most common are outlined below:

Bunny Ears:

1. Hold both laces
2. Cross over laces to make a X
3. One lace goes under and pull tight to make a knot
4. Create 2 ‘bunny ears’ (loops) with the laces
5. Cross over the loops
6. One loop goes under and pull tight to make the second knot.

https://www.twinkl.co.nz/resource/how-to-tie-shoelaces-t-t-2546436

Loop and Around:

1. Hold both laces
2. Cross over laces to make a X
3. One lace goes under and pull tight to make a knot
4. Make one loop and pinch close to the shoe
5. The second lace goes around the first lace
6. Push through the hole
7. Pull tight

 

 

Self- Feeding

Independent Self-feeding skills is an important part of Child Development. Below is a outline of the progression of self feeding skills.

Table of development of eating skills

Child shows interest in food.	Child starts to reach for food with his/her hand purposely and take to mouth. Accuracy of hand use is limited. During this phase, the child is spoon fed
Child helps use bottles	The child will hold a bottle or cup with assistance, placing both hands on the cup/bottle, but are not able to hold the cup or bottle on their own.
Child shows a interest in spoons and make more purposeful movements.	Children will be able to begin finger feeding skills, as they bring dry foods to their mouth such as cereal or chips with a scraping motion. Child will start to hold spoon with palmer grasp but no hand dominance so may swap hands Can lift a Sippy cup up to mouth to drink with both hands Child starts taking small sips from a regular cup with adult support Can drink from a straw
Developing accuracy using spoon	Child begins to dip their spoon into foods but no accuracy with scooping food Food may be turned upside down in their mouth The spoon may be held with a digital grasp (hold spoon in their fingers instead of palm) and the child will likely switch hands while holding the spoon.
Child starts to use both hands when feeding.	Child will start to support bowl of food with other hand while scooping food with spoon Child can hold an open cup on their own, pick up, drink, and set the cup down with just some spilling of the liquid.
Child continues to improve accuracy and begins to explore fork.	Typically, the child is able to self feed independently and may spill some food There will be greater control of forearm supination so that the palm is facing upward when scooping food Can drink from an open cup with one hand Child can use a fork to pierce soft foods and they can brink the fork to their mouth
Child develops accuracy when using a fork and shows increased interest in cooking.	The child will begin to use a fork with improving accuracy. They can also hold a cup while drinking from a straw independently The child will use both hands together with improving coordination in self-feeding. At this stage, it’s a great time to get kids involved in helping to cook recipes. This experience in the kitchen along with an adult supports development of fine motor, sensory motor, and visual motor skills.
Child starts to explore using a knife to spread butter.	Food spillage while self-feeding decreases Children will be able to use a knife to spread butter or peanut butter with the dominant hand while holding the plate or bread with their non-dominant hand. Beginning use of child-friendly knives is appropriate. Child may press with the knife rather than chopping or slicing.
Child is developing accuracy manipulating spoon and fork with increased control.	Child will use fork or spoon accurately They will be able to scoop, poke, and stab with a fork using appropriate positioning. May be without use of the non-dominant hand to support the plate. Child will begin to use knife to cut food
Child uses knife and fork combined.	The child will be able to cut meat with a knife with increasing accuracy and ability. As they develop, the child will increase coordination with knife and fork use in a coordinated manner.

Positioning for Mealtimes

When setting up your child for mealtimes it is important to consider how they are positioned as this facilitates good cutlery skills and supports a child’s concentration when eating. This ensures they feel stable and supported and are able to focus on the meal in front of them.

The Chair:

 It is important that the chair is a suitable size, to provide stability when eating try to ensure your child’s:

• Feet flat on floor (or footplate) and hip width apart.
• Bottom and back supported.
• Chair tucked in under the table.
• Elbows supported on the table.

If children are in specialist seating, ensure that they are firmly held in the chair with the lap and chest straps.

The Table

• Ensure that the child is sitting close to the table.
• Ensure that the table is at the right height so that the elbows rest comfortably on the table.
• Keep the table space clear from clutter. This will encourage concentration on eating. 
• Set the table with knives and forks (or forks and spoons depending upon your child’s age)
• Where possible encourage the child to help you set up the table while they wait for their food.

 

Supportive Equipment:

• Kura Care cutlery can support your child’s development of grasp through modified shaping of cutlery.
  • Available in ‘adult’ and ‘junior’ sizes from stores such as  www.nrshealthcare.co.uk & www.Amazon.co.uk 
• If your child’s plate keeps slipping when cutting, place a non-slip mat underneath the plate. (E.g., Dycem mats from www.dycem-ns.com or Maplin do a multi-purpose non-slip mat)

Strategies to support cutlery development:

• Practice knife and fork and spoon skills outside of mealtimes by encouraging your child to help with cooking and baking
• If needed give the child hand-over-hand help to guide him/her through the steps of holding the cutlery. Gradually reduce your help at each step as they learn to do it themself.
• Let children practice using the cutlery at the beginning of a meal when they are hungry.
• Provide opportunities or your child to use cutlery in play activities (scouping dry pasta or rice), using a fork when playing with playdough etc.

 

Sleep:

Everyone needs sleep to restore and rejuvenate, to grow muscle, repair tissue, and synthesize hormones. Between their second birthday and third birthday, toddlers need about 11 hours of sleep a night and a single hour-and-a-half to two-hour nap each day. But while it may appear that your child's sleep patterns are starting to resemble yours, your toddler will continue to spend more time than you do in light REM sleep until he or she is about four years old. The result is that your toddler will experience more partial awakenings throughout the night than you do, because he or she will be making more transitions from one sleep phase to the other. That's why it's important that your child learns how to soothe him/herself back to sleep.

Before you can teach your child to self-soothe you need to establish a bedtime routine. This should be the same every night, so that the routine remains predictable, and your child knows what to expect. To support your child’s brain to start to slow down it is recommended to stop using TV and other devices at least 30 minutes before bedtime.

1. Identify a reasonable time for bed. For newborns this may be as early as 6pm and for toddlers as late as 7pm. Do not be tempted to have a later bedtime, until your child is older than 5 years old.
2. Start your bedtime routine 1-1.5 hour before the appointed sleep time..
3. Try to incorporate calming components into bath and shower time with particular focus on the last activity, you can sing a slow song together, use the time when drying off their body to incorporate some big cuddles, in the environment you may dim the lights to help their body get ready to slow down and sleep.
4. Try to limit activities in your child’s bedtime routine once transitioned into the bedroom, you want to avoid your child having to go in and out of their bedroom as much as possible. A possible routine once  in the bedroom could include
   • Reading a book together
   • Telling a story or sharing favourite parts of the day
   • Cuddles
   • Reminders that it is bed time and time to sleep
   • A gentle massage with massage oil with a sleepy fragrance may support your child if your child is soothed by touch.
5. Try to encourage your child to settle to sleep by themself, with your support nearby if needed. They may use a comfort tool (blanket or soft toy) to support this transition.

Once you have established a routine you will need to teach your child to put themselves back to sleep if they wake up.  Since your child was born, you responded quickly to every cry, coo and wail and anticipated your child’s needs. Now that your child is older he/she can be taught how to rely on his/her own internal resources so he/she can get back to sleep. This is not a process that is completed in a week--it will take time, so plan carefully how you are going to teach your child this important skill.

• Give your child the opportunity to learn to self-soothe when he/she wakes up during the night. Rather than running into their bedroom on the first holler or cry for you, hold off and see if they can figure out how to get back to sleep himself.

ENVIRONMENTAL CONDITIONS OF THE BEDROOM

• Consider bedding and clothing. Use unscented laundry detergent and in general, if your child is bothered by smells avoid fabric softener because it leaves a residue. Make sure the mattress is not lumpy, too hard, or too soft.
• Heavy blankets may assist your child with falling asleep but ensure your child is able to push them off if desired
• Make the bedroom conducive for sleep. Use a night light if your child prefers one, but consider whether your child needs the room to be completely dark. Minimize environmental noise by keeping the house relatively quiet, you may try using a white noise machine.
• Keep the bed for sleeping, so refrain from getting your child in the habit of associating his bed with anything other than sleeping.
• Make sure the room is set at a consistent temperature throughout the night in order to minimize night time awakenings.

Nail-Care:

Most young children do not enjoy nail trimming. Children with additional needs may genuinely find your touch irritating, or painful, and they often have very little tolerance for the things that they do not want to do or struggle to understand. Also, nail trimming is usually an occasional event, not a daily part of a familiar routine.  Rare events are almost always seen as unwelcome or even threatening.

There are some things that parents can do to make nail trimming less aggravating.  Here are the most successful strategies:

• Use child-like language, simplifying what you say, and empathising can reduce the resistance.  Children will then understand that you get their point of view. Just hearing that you know they don’t like it, is sometimes enough to help them allow you to trim their nails. For children with Autism you may use social stories to help break down the task.
• Choose a comfortable position for both of you. You might increase motivation with A TV show or movie whilst cutting nails.  
• Make it clear why their nails need attention. Scratchy nails need to be trimmed or they are too long and too sharp.
• Use good technique and equipment.  There are nail cutters that protect children’s fingers better than the standard clippers you buy for yourself. There are many types of clippers available in the market, including baby clippers. This will avoid any accident.

• Pair the experience of nail trimming with something your child enjoys.  You could try offering a snack, playing a game together, or doing what they like right after nail trimming.  Use now and then cards. Now trimming, later (reward).
  • If trimming nails is very tricky start with filing nails first, Daily filing can be less scary and still keep things well groomed.  Once filing is well tolerated, you may be able to move to clipping. 
  • Try to do a small trim on a weekly basis (or even more frequently) so that it can be expected and part of a routine.  Familiarity really helps all of us. 
  • For children with severe avoidance/ distress it may be useful to do it while the child is asleep.
  • Nails are softer after bath so this can be a better time.
  • If the child is older to encourage them to do it themselves to increase control over the activity.

And remember to be patient with yourself as well. It is very challenging to parent a child with specific needs. You are doing a good job! Keep up!

The head is an area of the body that can be especially sensitive for many children. Children with these sensitivities often resist attempts to brush their hair making it a difficult part of the daily routine.  The severity of your child’s reaction may differ on a day-to-day basis however a pattern of resistance or avoidance is usually apparent.

General strategies:

• Being aware of the temperature, noise and feel of the of the water on your child’s skin when hair washing. 
• Consider the type of brush you use and give your child a brush to play with at different opportunities e.g. at bath time, in the car.
• When haircutting, it is helpful to approach the child from the front so he/she is aware of the activity
• Early appointments might be less crowded and calmer for your child to handle the situation.
• Children can be actively involved in saying that they are ready to start the activity.
• Ask if this is something they would like to do while seating, like watching their favourite movie on an iPad.

Bathing and washing:

• The sensory experience of showering or bathing can be over whelming. Be aware of the room, floor and water temperature as well as the pressure and noise of the water. This can make bathing an uncomfortable experience. Strategies to support your child’s sensory needs in the bathroom include:
  • Increase predictability as much as possible, tell your child before placing water on any part of their body or using the wash cloth i.e. “let’s wash your arm ready..1…2…3 and done!”
  • Dim the lights in the bathroom to decrease the level of sensory input
  • Use calming scents or unscented soaps if you child is bothered by smells.
  • If you child is bothered by the sound of running water, fill the bath before brining them into the bathroom.
  • Offer bath toys for your child to play with when in the bath.
• Establish a bathing routine by having a bath at the same time where possible.
• Make bath time a fun activity by using toys that your child likes.
• Using music for bath time to create a calming environment.
• As your child starts to learn to wash their own body, visual can be used to help them sequence and understand each step of showering/bathing.

 

 

Hand washing:

• Use the visual to support your child follow the steps for handwashing.
• Provide hand over hand support to guide each step.
• Consider the smell and texture of the soap.
• Incorporate games and songs with hand washing.
• Use rewards that your child would like for hand washing