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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)

Topics Notes

1. Characteristics of the Disability

2. Instructional Strategies

3. Lif ting

4. Feeding (food issues)

5. Toileting

6. Assistive Technology and Adaptive Equipment

7. Orientation and Mobility

8. Transportation

9. Sign Language10. Behavioral Strategies

11. Data Collection

12. Job Coaching

13. Restraint Techniques

14. Confidentiality

15. Socialization Issues

16. Communication Issues

17. Safety Issues18. Sensory Impairment

19. Early Intervention

20. How to be a Shadow in a Child Care Center

21. Basic Educational Terminology

22. Other

23.

24.

25.

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 wouldlike 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

Wha t topics do I needto know more ab out for

my jo b?Wh ere c a n I get t h e

inform a tion/tr a ining ?

Wha t a ctionsteps a m I going

to t a ke ?

Wh en will Icomplete

th is ?

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District, IU, Preschool Agency

PolicyYour local district, IU, preschool or

employing agencys policies regarding

paraeducator job descriptions, duties,and responsibilities provide the finalword!

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Agenda for today

Learning ObjectivesDaily Living Skills definedDaily Living Skills in the school environmentFactors influencing student attainment of daily

living skillsDressing, Hygiene, Grooming, Feeding, Toileting

Techniques for teaching skillsThe importance of collaborationTime for Questions

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Learning ObjectivesIdentify the functional daily living skills addressed inmost educational environments

Recognize the essential sequence of abilitiesassociated 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 professionalsinvolved in teaching children daily life skills

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Activities of Daily Living are thebasic 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 (thattime is slightly higher for thosepeople with disabilities)

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Our focus for today

EatingBathrooming/Toileting

DressingHygieneGrooming

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Eating at School

Finger feedingOral Motor abilities (bite, chew, food textures)

Cup drinkingUtensil Usage (spoon, fork, knife)Managing the lunch lineOpening containers (milk carton, fruit containers,

chip bags)Drinking from a water fountain

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Toileting at School

Sensory AwarenessCommunicating the need to voidPostural stabilityClothing managementHygiene skillsTransfers/MobilityUse of adaptive devices (ex. catheter)Feminine hygiene

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Dressing & Clothing Management at School

Taking on and off coatGloves / hatClothing management during toileting tasksDressing for gym classShoe tyingManaging fasteners on book bags

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Grooming at School

Combing Hair Washing faceWashing HandsBlowing / Wiping Nose

Aspects of ToiletingBrushing TeethNapkin usage

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Factors InfluencingLevels of Independence

Students personal motivation

Cognitive, Motor, and Sensory abilitiesDevelopmental ReadinessPhysical Status or ConditionsFamily Expectations / PrioritiesOpportunities to practice and generalize skills ona routine basis at school and home

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Many of the children we work with do notfollow the expected developmental

sequences for these skills, hence these

levels can only serve as guides.

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Sensory Preparation

Tactile considerationsMassageLotion

Physical Play

Heavy Work Activities

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Developmental Self-FeedingSummary

Handout A

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Oral Stimulation is Foundational to

Childs Sense of Self

Map of face, mouth, head in relation to

rest of bodyOral stimulation facilitates alertness andself regulation

Smell facilitates alertness and enhancesmemoryEating may help with speech development

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Preparing the Child

Posture

CommunicationSensoryOral-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/TongueInadequate Lip Closure

Tongue ProtrusionTongue ThrustingTonic Bite Reflex

Jaw ThrustingJaw Clenching

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Abnormal Sensory Reactions

Refusing FoodPicky eating (prefers soft foods thatdissolve easily with saliva in mouth)GaggingVomitingStuffing Food into MouthSucking FoodLimited Textures/Diet

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Sensory Influences

Thin vs. Thick LiquidsTexture

TemperatureWet vs. Dry FoodsFood Tastes

Visual AppearanceSmell

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Behaviors

Food refusalFood selectivity

Mealtime tantrumsExcessive meal durationRumination

Pica

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Gastroesophageal Reflux

Frequent return of stomach contents intoesophagus

Anatomical and Physiological factorsGER may be associated with vomiting butis also gastric contents to any level of esophagusDifficult to establish and diagnoseLinks to apnea, respiratory arrest, SIDS

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Aspiration

Accidental inhaling of food into airwayCan occur during swallow, with a depressed or absent swallow, or with refluxAspiration pneumonia - an inflammation of thelungs and bronchial tubes caused by inhalingforeign material, usually food, drink, vomit, or secretions from the mouth into the lungs. Thismay progress to form a collection of pus in thelungs (lung abscess).

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Allergies

Allergies and nutrition

Anaphylaxis is an allergic reaction that canbe fatal within minutes, either throughswelling that shuts off airways or through adramatic drop in blood pressure.

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Communication

Developing a trusting relationship with thefeeder

Reading childs cues & communicationattemptsAcknowledging childs feelings

Giving child some control over feedings

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Making Mealtimes Enjoyable

1) Coordinate presentation of food withchilds breathing and movement

2) Give child clear view of food with proper positioning and lighting3) Use smooth and predictable pace

4) Feeder uses ready signals5) Wait, observe and reinforce signals6) Minimize distractions and interruptions

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Making Mealtimes Social

Determine what levels of social interactionwill facilitate/motivate childs feeding

Include peer/s for appropriate portions of feedingUse 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

BreastBottle

NG / G-TubeSpoonSelf-Feeding Finger, Utensil

CupStraw

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Why Toileting?

Self Esteem

Social SignificanceInclusion in community activitiesVocational Implications

Life after School

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Developmental Toileting Considerations

Toileting consists of training the sphincter reflexes anddeveloping the volitional holding of urine and feces

This typically happens after a child begins standing andwalking

This action is reflexive until the spinal tract is myelinatedto 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 30months

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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ReadinessChronological age

Mental / Developmental Age

Does the child notice or sense when diapers or pants are soiled?

Does the child exhibit interest in toiletingbehaviors?

Are there medical considerations or conditionsthat would impede toileting success?

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Strategies

Use toilet at regularly scheduled timesDevelop a toilet routineUse of visual schedule to support routine

Use specific concrete steps / cuesCharting of responsesAddress waking hours firstProvide all necessary materials within easyreachUse clothing that promotes independenceUse of Social Stories

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Other considerations

Communication

Positioning

Special Equipment / SeatingSupporting Feet

Monitoring 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 magazinesReducing distractions

Dimming lights if possible

Providing some privacy where possible

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Developmental Pre-Dressing

ChecklistHandout B

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Dressing tips

Make dressing tasks routine (daily practice is amust)

Present the task in a systematic sequence of stepsRemember motorically, it is easier to undress than

to dressConsider positioning to optimize task performance

Use of visuals

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Hygiene & Grooming Skills

Hand/Finger DexterityBilateral SkillsTool Usage

Motor planningKinesthetic and tactile sensations

Most children have the motor skills to complete the

actual grooming or hygiene task, but not the awarenessand responsibility to perform them.

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Developmental Sequence for Independent Hygiene/Grooming Skills

Turns faucets on/off - 3 years of ageWash/dry hands/face 4 years, 9 monthsBathing 8 yearsDeodorant 12 yearsCares for teeth 4 years, 9 monthsCares for nose 6 yearsCares for hair 7 years, 6 monthsCares for nails - 8 yearsFeminine hygiene Puberty

(Pratt & Allen 1989)

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General Techniques for DailyLiving Skills at School

Standard teaching approach/sequence

RemediationCompensatory ApproachesAdapting task or approach

Use of Assistive TechnologyConsistent Motivation and Reinforcement

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Techniques

Backward ChainingTrainer prompts student through entire processleaving the last step for the student to perform.Once that step is mastered, the student addssteps from the end of the process to thebeginning until he/she can perform the wholetask.

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Techniques

Forward ChainingChild is taught the first step in the sequence of task. After mastery of the first step, subsequentsteps are presented in order until the child canperform the whole task.

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TechniquesSystematic Cueing

Visual or Gestural prompting

Visual schedulesVideo TapingUse of mirrors

Physical prompting

Hand-Over-Hand assistance

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Team Members

Parents/GuardiansTeachers

Occupational TherapistSpeech TherapistPhysical Therapist

NurseEducational Paraprofessionals

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It is important to remember that allindividuals working with a student on thesame tasks should be consistent in their

approaches, cues, and language to bestpromote skill development.

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Learning ObjectivesIdentify the functional daily living skills addressed inmost educational environments

Recognize the essential sequence of abilitiesassociated 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 professionalsinvolved in teaching children daily life skills

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Upcoming Videoconferences

A pril 26, 2006

Legal Issues in Special Education: WhatParaeducators Need to KnowMa y 17, 2006

The Competent Learner Model

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Upcoming Regional TrainingSessions

A ugust Live Tr a inings:

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