Stages of cutlery

• Introduce a children’s spoon to your child between ages 9-12 months as a play object- usually after weaning.
• Let the child play with the spoon, mouth the spoon and learn how to hold it.
• Once your child has established grasping the spoon and bringing it to their mouth, put food onto the spoon and provide hand over hand assistance to guide the movement.
• Giving sticky foods (porridge, rice pudding, mashed potato) help keep food on the spoon whilst the child practices independent feeding.
• Once confident with the spoon, introduce a children’s fork to your child.
• Allow them to practice ‘stabbing’ and picking up soft foods (fruit, boiled vegetable) with the fork.
• Encourage the child to hold both spoon and fork together to get them used to holding two pieces of cutlery.
• When confident with using the fork to pick up food, introduce a children’s knife to the child.

Preparing to use cutlery

• Check your child’s posture whilst sitting at the table- their feet should be supported and the table at a height they can rest their elbows easily.
• Use appropriate sized cutlery for your child- plastic children’s cutlery is easier to handle than adult sized metal cutlery.
• Start with cutting soft foods (soft vegetables, soft potatoes) and gradually work towards firmer foods.
• Non-slip mats (Dycem mat) help to keep the plate still.
• Plate guards also help to keep food on the plate whilst scooping and cutting
• Encourage use of ‘pointy’ fingers (index finger) to guide the cutlery when cutting. Caring cutlery can help with this (see ‘alternative options’).
• Provide visual guidance to your child- demonstrate how to hold the cutlery and ask your child to copy.
• Provide children with opportunities to use cutlery in play – Mould playdoh into ‘pretend food’ and practice scooping or cutting it up using the cutlery.

Common signs of difficulty

• Reluctance to use cutlery and opting for finger feeding.
• Avoidance of foods needing cutleries.
• Avoidance of feeding themselves
• Difficulty holding cutlery- may look awkward or have a poor grip.
• Messy

Using a cup

• Start with a cup / beaker with two handles — progress to one handle — progress to no handles.
• No-spill cups are a good tool to practice the drinking motion.
• Using thicker drinks help the child control the cup/liquids whilst learning.
• Provide hand over hand assistance and verbal prompts / encouragement / praise throughout learning.
• Expect spillages whilst your child is learning to use an open cup.
• Providing a special drink mat to place the cup down after drinking reminds the child to place it before letting go.

Activity ideas

The below activities are useful to develop the skills required when using cutlery: using two hands together, tripod grip, finger/hand strength:

• Colouring with one hand whilst the other steadies the paper.
• Construction games – Lego, bead threading, K’nex.
• Cooking/Baking – Mixing ingredients with a bowl and spoon.
• Opening screw bottles and jars.
• Using a dustpan and brush- keep dustpan still whilst using the brush.
• Using playdoh / modelling clay- use cutlery to cut ‘pretend food’.
• Using scissors – progress from easy to firm paper/card for resistance.

The below activities are useful to develop the skills for using an open cup:

• Blowing a whistle or bubbles.
• Tipping water from one container to another.
• Rolling, pulling and pinching play doh.

Alternative Options

1. ‘Caring Cutlery’ are useful as they have a groove to prompt the child to place their fingers for better hand positioning.
   
2. Foam Tubing provides a built up handle for better grip.
   
3. Angled cutlery for toddlers for easier hand to mouth feeding.
   
4. ‘Knork’- combined cutlery for single handed cutlery use.
   
5. Weighted cutlery can provide better grip and control for children with motor control difficulties.

Eating with a spoon independently

Although I am learning to use a spoon to eat more independently, it is usually turned over just as it reaches my mouth.  Most of the food should still reaches my mouth, but expect some spilling and a mess!

Ideas to Help

1.    Use foods that are easy to scoop and will stick to the spoon when travelling from the dish to my mouth, e.g. mashed potatoes, thick pudding, cream of wheat, yogurt, cottage cheese.

2.    Use a bowl with a high edge or a ‘scoop plate’ with a high curved edge on one side (higher edged side positioned toward direction I am scooping).  High edges give me something to scoop against.

3.    To help prevent the dish from sliding or toppling over  place a non-slip mat underneath the plate.

4.    Let me practice eating with a spoon at the beginning of a meal when I am hungry.  Let me finger feed when I want to.

5.    If I need it give me hand-over-hand help to guide me through the steps of holding the spoon, scooping and taking the food to my mouth so I can learn the movements needed. Gradually reduce your help at each step as I learn to do it myself.

6.    Give me extra practice in handling spoons during play:

• Scooping wet or dry sand into a bucket or box to make a hole.
• In the bath use a spoon to scoop Soap suds or shaving cream into pots.
• Play with spoons and pots scooping uncooked macaroni or rice in a large box.
• Pretend Play: cooking/stirring/feeding dolls
• Helping you with baking: stirring the ingredients, measuring with a spoon.

7.    If I have a weak grasp or other difficulties in grasping, a thicker spoon handle may be helpful. Wrap a layer of sponge around the spoon handle with masking tape to build it up or inquire about commercially made adaptive spoons which have built up handles.  Make sure the thickness allows for a comfortable grasp.

Knife and fork skills — learning to cut

Children need to be taught how to use a knife and fork. Follow the steps below to help your child learn this skill.

1.    Sit at the table! Good positioning is very important. Remember to sit them with their bottom back on the chair, feet flat on the floor (or resting on a box) and elbows level and at table height.

2.    Ensure there are minimal distractions e.g. toys away, TV off etc.

3.    Make sure your child holds the knife and fork by the correct grips with their index finger extended to stabilise the knife and fork.

If they are finding it difficult to maintain this grasp on the cutlery, try using ‘Caring Cutlery’ as it has indentations on the handles to show your child where to place their fingers. 

4.    Actively ‘Teach’ your child the correct technique for using a knife and fork:

• First Step: ‘Stab’ the food with the fork
• Second Step: ‘Saw’ with the knife. Put the knife in front of the fork and move the knife back and forward in a ‘swing’ motion, rather than just pushing it through the food. 
• If your child finds this difficult, place your hands over theirs and show them how to move their knife and keep their fork still

5.    To increase your child’s sense of success, start them off with cutting softer foods such as fish, egg, soft potatoes and well-cooked vegetables.

6.    If your child’s plate keeps slipping when cutting, place a non-slip mat underneath the plate.

7.    Practice knife and fork skills outside of mealtimes by cutting up pretend food made out of playdoh or plasticine.

Remember that the Correct Technique and PRACTICE is the only way to master these skills.

Spreading butter on a piece of bread

In preparation- ensure all items needed are of reaching height

1. Gather plate, knife, butter and bread
2. Put bread on plate
3. Hold knife with pointing finger halfway down the back
4. Wrap thumb round knife 
5. Put rest of fingers gripping round the knife (making a fist holding around the knife)
6. With a scraping motion put about 2cm of butter on the knife using helper hand to keep it still
7. Stabilise the bread using thumb and pointing finger spread out where comfortable
8. Start with the knife on the top of the bread tilting it slightly forward distributing butter as you move down 

Extra help- If the plate is moving around whilst spreading a non-slip mat can be used underneath plate.

To make it easier for understanding how to hold knife you can put a mark on the knife where pointing finger goes.

If you are not using butter on toast and the butter is too hard to spread, then ensure you have got it out of the fridge sometimes before to make is easier.

You can sing ‘down, down, down, down, stop’ as you reach the bottom of the bread.

Ensure the butter dish is easy to get butter out of.

Learning to do up buttons

Practicing on adapted clothing

• Practise on an item of old clothing which can be adapted if necessary.
• Sew coloured buttons onto a white shirt so the buttons are easier to see.
• Start with larger, chunkier buttons such as wooden buttons/toggles as they are easier to feel and grasp.
• Buttonholes can be enlarged carefully without cutting vital stitching by cutting a snip at the corner. This will help when learning to do buttons as a bigger hole is easier to pass the button through.
• Begin with large buttons and sturdy fabric, progress to smaller buttons and floppy fabric.

Motivation

• Let your child help do up your jacket, involve other family members
• Play dressing-up
• Dress a large doll or teddy in a pyjama top with big buttons
• Collect interesting buttons from old clothes or market stall, and use for posting, or passing through slits in card, or through button holes
• Give enough help to ensure success

Consider how and where to practise

• Your child will find it easier to practise on clothes in front of them, on the table or her lap than if she is wearing them. Once she can do this progress to buttoning clothes while wearing them.
• Practise when you and your child have time. Rushing makes it harder to learn.
• Avoid other distractions such as the TV when trying to teach your child a new skill.
• Buy clothes with easy buttons on them like cardigans, coats and pyjamas. This will allow your child to practise buttons regularly. Pyjamas with buttons are a good starting point as most families have more time in the evening to practise dressing activities.

Learning the Technique

Button skills can be broken into steps, just like any other dressing activity. Then use either a backward chaining or forward chaining method to teach your child. See the separate sheets for these techniques.

If it is too much for your child to learn the whole task at once, just work on one step and then build on this.

Steps for doing up a button…..

• Hold the button hole open with the first hand
• Pinch the button between finger(s) and thumb of the second hand
• Poke the button through the hole, letting go of the buttonhole and grasping the button instead with the first hand
• Let go of the button with the second hand and grasp fabric instead
• Pull button through
• Wiggle or turn it to make sure it is right through the hole

Steps for undoing a button:

• Grasp the fabric next to the button hole with one hand
• Grasp the button with the other hand
• Pull apart a little until you can see the hole open up
• Push the button through the hole; turn it if necessary
• Grasp the button with the other hand
• Pull the edge of the fabric back to reveal the button and pull hands apart

Zips

When starting out

Choose clothes with chunky zips or larger zips

Alternatively with small zips add some cord or a tag onto the zip pull to make it easier for your child to hold and pull up the zip.

Try getting your child to sit down when inserting the zip as it makes it easier to see what they are doing (however it may be easier to stand up when pulling the zip up)

You may need to initially give your child hand over hand help so they can understand how their hands need to ‘move’ when doing up zips.

Teach the steps

Ensure you are teaching each step of the task to your child, don’t expect them to just ‘get it’ without you teaching the steps. Break the activity into simple steps and use simple language to teach each step. For example:

• Bring the zip pull all the way to the bottom of the zip
• Hold the zip pull and the metal end together with one hand
• Hold the zip point with the other hand
• Insert the zip point into the zip pull and push it all the way down (keep the hand holding the zip pull still)
• Now hold the metal end and zip point together with one hand and pull down so the jumper/top is stretched.
• Pull the zip pull upwards with the other hand.

For children who are not quite ready to learn all the steps from the beginning or get frustrated easily and then avoid the task, try a backward chaining approach

Backward chaining

Initially you complete the entire process, but leave the last part for your child to do. You then gradually increase the amount your child does of the task, but by working backwards. Your child should always end the task themselves, so they experience success at the activity. 

Example of backward chaining steps:

Start with step one, when they have success at step one, move onto step 2, then they can do this move to step 3 etc.

1. Your child pulls’ up the zip to the top when its already three-quarter zipped
2. Your child pulls up the zip when its one-quarter zipped
3. Your child pulls up the zip from bottom, with zip already fastened 
4. Your child holds the zip pull and metal end with one hand whilst you insert the zip pointer. 

Orientation of the ‘zip point’

If your child is having difficulty understanding and orientating the ‘zip point’ into the ‘zip pull’ and ‘metal end’, try putting a dab of coloured nail vanish right on the end of the ‘zip point’ and around the hole of the ‘zip pull’. Teach you child that the coloured tip needs to go into the coloured hole.

Common problems with dressing

Poor balance

Possible solutions:

1.   Sitting on a chair or firm bed with their feet supported on the floor.

2.   Sitting against a wall or in the corner of the room.

3.   Standing against a chair or wall for support.

Clothes are put on inside out or are poorly adjusted

Possible solutions:

1.   Use contrasting lining – different colours and textures from outside to inside.

2.   Use contrasting sleeve linings from the rest of the lining.

3.   Draw your child’s attention to clothes that have been put on the wrong way round.

4.   Put labels on the inside of clothes.

5.   Use a mirror for your child to check their clothes are all on the right way. 

Clothes are put on back to front

Possible solutions:

1.   Lay clothes down on the table front down.

2.   Roll clothes up slightly to give extra grip.

3.   Put a special mark inside clothes to show your child which way is the front.

4.   Use patches and textures to help your child remember which where the front, back and right and left sides are.

5.   Dress your child with t-shirts and sweatshirts with a picture on the front.

Arm and head holes get ‘lost’

Possible solutions:

1.   Lay clothes flat out in front of your child with the arms showing.

2.   Encourage your child to put their arms in first so they can’t be lost and then put their head in.

With a coat:

1.  Drape the coat over the back of a chair with the lining facing outwards and the    sleeves hanging freely. Your child stands with his back to the lining and puts each arm in turn into the sleeves. He then bends down to fit his shoulders in, and then move up and away to release the coat.

2.  Place the coat open, with the collar nearest to your child and the lining uppermost. Your child slides their arms into the sleeves and swings the coat over their head. Try using slippy, silky linings to make it easier to put the coat on and off.

Clothes are put on in the wrong order

Possible solutions:

1.  Make a list showing all the steps necessary in order to get dressed. Use photos or pictures if it helps.

2.  Store all items of clothing in order i.e. Underwear in the top drawer, t-shirts in the next drawer down etc. Remember to be consistent in your ordering.

Dressing becomes stressful at a particular time e.g. in the morning, getting changed for p.e etc.

Possible solutions:

1.  Practice dressing outside of these times, when not in a rush.

2.  Make sure that your child has enough time to get dressed/undressed.

Confusion between left and right

Possible solutions:

1.  Put small ‘r’ and ‘l’ stickers inside shoes to help your child remember which shoe goes on which foot.

2.  Wear shoes with fastenings or stripes on the outer edge to act as a prompt.

Sock heel gets twisted to the front of the foot

Possible solutions:

1.  Don’t wear socks that are too tight.

2.  Wear socks with marked colours on the toes and heels.

3.  Tie / sew a loop of ribbon onto the edge of socks for your child to hold when pulling  the sock up.

4.  Try with tubular socks.

Methods for teaching dressing skills

There are many methods to help your child develop their dressing skills. Choose one that will work for you and your child and fit into your routine.

Quality of practise and consistency are important even if you can only practise 3 or 4 times a week.

When practising make sure you have enough time since it often takes longer than expected. It may be easier to practise over the weekend, when getting ready for bed or during holidays than when rushing to get ready in the morning. 

Ensure the environment is as distraction free as possible. (Turn off the TV or radio). 

Method 1: forward chaining

Encourage your child to put on the first item of clothing e.g. Their pants. Then give lots of positive praise and put on the rest of the child’s clothes on for them, all the time verbalising what you are doing. 

When your child has mastered the first item, encourage them to put on their pants and then the second item e.g. Vest. Continue with this until your child has also mastered this item and you can move on to the next one.

Method 2: backwards chaining

Here you dress your child, until you reach the last item of clothing that needs to go on. Encourage your child to put on this final piece of clothing independently. When they have mastered this, the next step is to dress your child up to the second to last piece of clothing that needs to go on, so that they now learn the last two steps. Continue with this until you only dress your child up to the third last item to go on, and so on.

Note: backward or forward chaining could also be used within the one task. For example, your child could try the first step of putting socks on by putting their toes in. You now assist by pulling them up (forward chaining). Alternatively you could put the socks on your child up to the final step, where your child then pulls them up the ankle (backward chaining). 

Method 3: verbalisation of methods using a plan

For this method to work, it is important that you describe the order and what you are doing to with your child. Try and use the same language and verbal prompts every time e.g. ‘i am now / you are now putting your right leg in’. Ask your child to describe all the stages of the dressing process as they are being carried out.

Method 4:

This strategy breaks down dressing into 5 components, bearing in mind that the gross motor components e.g. Trunk and whole limb, are mastered before fine motor tasks like doing up buttons using the fingers:

1.    Stepping in and out (of trousers, pants etc).

2.    Arms up and through (t-shirt, coats etc).

3.    Pulling items over the head (pullovers etc).

4.    Straightening / adjusting clothes.

5.    Doing up buttons, zips etc.

The task is then to work on each component at a time e.g. First use games and toys that encourage your child to reach up in the air (for pushing arms through jumpers etc). When this skill is developed, use it in dressing and move onto another skill area.

Compensatory strategies:

Sometimes your child may not be ready or become distressed when attempting a complex task e.g. Tying shoelaces. If it is particularly important for the child to be independent in a certain task, then compensatory strategies could be used e.g. Velcro or zipper fastenings on shoes, pull shoelaces etc. When the child appears ready, tying shoelaces can then be reintroduced.

Other useful strategies:

• Use hand over hand techniques to help your child and give them guidance. 
• Roll up clothing so that you create more grip e.g. Roll up the edge of a jumper before putting it on. 
• Place elastic around waists or cuffs to increase gripping.
• Play games using quoits, place them over arms and legs and pull them off with the other hand.
• Practice stepping into hoops and pulling them up over the body.

Strategies and advice for toilet training

It is important to remember that toilet training is a gradual process and setbacks are normal. Whenever you begin toilet training you need to have a positive frame of mind to achieve success. Achievement is significantly affected by emotional stress, excitement or new surroundings. Remember that progress may be limited by difficulties with understanding and communication, sensory awareness and general health.

Before you begin consider the following points:

• Medical issues – Any problems that may be making toiletting difficult (e.g. constipation) should be checked medically and resolved before commencing a toiletting programme. Adequate fluid and dietary intake is important.
• Environment - An environment that promotes mastery is calm, relaxed and familiar.
• Consistency - It helps if the environment is consistent, therefore starting at the beginning of a school holiday when your child is at home may be helpful.
• Cooperation – Toilet training will only work if your child co-operates with you. The more pressure they feel from you to perform the less they will respond. Encourage cooperation from them, not resistance and avoid confrontation.
• Timing – Don’t be tempted to rush into toilet training. You have to pick a time that is right for your child and you. There is no point in starting the process until your child is ready.
• Communication - Establishing how your child is able to indicate their toileting needs is very important. They may vocalise, gesture, behave in a certain way, sign, eye point, use symbols or any combination. Seeking advice from your child’s speech and language therapist may be appropriate in this area. Whatever means is decided upon, it is essential that anyone involved in your child’s care is able to recognise / look for this communication and respond to it in a consistent way to yourselves.

If a symbol is used, it may be helpful to have an enlarged version on the wall or other appropriate prominent place so that your child can access it quickly and communicate their need. Initially, to introduce the idea, you will need to point to the symbol yourself and maybe take it with you on each toilet visit.

Positioning and Equipment

Toileting requires children to adopt a good sitting position, which allows them to press down for emptying the bowels. The child will need to feel secure in order to use a toilet or potty. They will need to be able to relax and sit forward so that they can push with their abdominal muscles to empty their bowels, i.e. both feet flat on the floor and bending at the hips and knees. Some children may need to hold onto something (e.g. a bar) in order to feel secure and relaxed.

The following skills are important for children to have, and difficulties in any of these areas will require assessment and advice from an Occupational Therapist who may recommend assistive equipment or alternative strategies.

1. Good trunk control.
2. Good head control.
3. The ability to bend at the hips, knees and ankles.
4. The ability to maintain knees apart.
5. The ability to keep feet flat on the floor.
6. The ability to bring arms forward to hold onto a support.

Sensory Issues related to toilet training

The process of toileting shows the development of the awareness of sensations, communication and the understanding process.

Including: -

• Being aware that the nappy is wet or soiled (a soiled nappy is usually recognised first). You may or may not notice your child do this.
• Your child indicates to you that their nappy is soiled. This may be a non-verbal or verbal cue such as crying, becoming distressed, pointing or using words.
• Having an awareness of a full bladder or bowel – you may or may not notice this.
• Your child lets you know that it needs to empty bladder/and or bowel. This may be via verbal or non-verbal gestures. Your child may let you know when they start to pass water or faeces or just before.
• Your child begins to let you know when to get the potty.
• Understands the sensation of a full bladder/bowel. 
• Your child may get or ask for the potty.

To help your child recognise a wet/soiled nappy: -

• When drying your child, after a bath/shower use a rougher towel than normal. You can dry them rapidly and firmly over their bottom and top of thighs (do not carry out if your child has nappy rash or is sore).
• You can use baby lotion over the skin.
• Encourage exploration of different textures and touch such as playing with foodstuffs like dried pasta or cornflakes. Also finger painting with sand or sugar mixed in for added texture.
• Play games that involve clapping, stamping and rough and tumble as they all increase awareness of movement and sensation.
• Letting your child stay in a slightly  soiled nappy slightly longer than usual may also increase awareness (do not do if your child is sore or has nappy rash).

Method for toilet training

1. Keep a chart of when the child’s nappy is soiled every two hours over a two-week period. Note any patterns of behaviour relating to bowel movements. Also note daily pattern of drinks and mealtimes. A warm drink may help induce bowel movement). This will help you to see when the child usually empties their bowels. Use the chart to identify 2 or 3 times a day when the child is most likely to have a bowel movement.
2. Once you have identified times the child is likely to have a bowel movement, sit the child on the toilet / potty at these regularly at identified times. Keep a consistent schedule. Frequency can be adjusted as you realise your child’s routine.
3. Initially let them sit for a very short period of time. Avoid making a fuss when they fail to perform or wets / soils in between times. Give positive encouragement to try again another time.
4. Gradually progress to sitting on the toilet without a nappy, and for a slightly longer time.
5. Introduce pants. Children associate pants with older children and being independent.

General Strategies

• Think positively. Think about the pleasant feeling you will have when progress is made rather than the wet carpets.
• Help your child to think positively. Take them out to buy a potty, make it a present. 
• Talk to them to familiarise them with the situation. Tell them what you are doing and what you expect. Try to make it a pleasant time and encourage them to relax.
• Help them to feel secure by staying with them.
• Try to avoid distracting activities which may lead to your child forgetting what they are doing. Focus and concentration is essential to learning bowel / bladder control. 
• Always give lots of encouragement and praise when going to the toilet. Rewards in the form of a reward chart may be motivating for the child.
• Allow child to feel uncomfortable by taking them out of nappies and use trainer pants and easily washable clothing. Hopefully the sensation of feeling wet / soiled in this way will encourage a sense of anticipation. 
• Encourage your child to take responsibility. Encourage them to un/dress themselves and wipe their own bottom.

Learning to wipe

Environment

Consider the toilet environment, the child may find it difficult to wipe because he/she physically finds it hard to balance when carrying out this action. Your child must have good posture on the toilet so wee and poo can be easily passed. He/she needs to sit with his/her bottom well back on the toilet seat and with his/her feet either on the ground or on a box or child’s step so his/her knees are bent by at least 90º. If the child has his/her feet supported he/she should feel more secure about wiping with one hand.

The child should be encouraged to stay on the toilet until he/she has completely finished pooing. Teach him/her to slightly strain to push the poo out and encourage him/her to sit for 5 minutes using a timer. 

Wiping

It is important that the child learns to wipe from front to back when cleaning after a bowel movement. Teach him/her to wipe with firm hand-over-hand assistance, as he/she learns the movement gradually loosening your hand grip and let him/her take control. Teach him/her to check the toilet tissue after each wipe to see if there is poo on it, tell him/her to keep wiping with new bits of tissue until there is no poo on the tissue after he/she has wiped. Moist toilet tissue wipes (like ‘kandoo’) can be useful to use. The wet texture will be sensory stimulating and give the child more feedback about where the tissue is when he/she can’t see it.

Toileting resources

NELFT OT Toileting Readiness.docx [docx] 106KB

NELFT OT Toilet Timing .docx [docx] 108KB

http://www.eric.org.uk 

http://www.promocon.org.uk

Increasing motivation and independence with teeth brushing

Brushing your teeth is an essential part of oral hygiene and good habits should be established in earliest childhood.

We recommend that all children brush their teeth twice each day; in the morning and last thing at night. Have set times that your child brushes their teeth so that it becomes a set part of their morning and evening routine, for example: bath, pyjamas, brush teeth, story and bed.

It is recommended that children receive assistance to brush their teeth until at least the age of seven when they have developed the coordination required to reach all their teeth. Encourage your younger child to have a go at brushing their teeth first before you take over. Children with additional support needs may need assistance beyond the age of 7.

Many children with additional support needs benefit from visual prompts to support their understanding of routines. Include a picture of tooth brushing or a tooth brush in your child’s morning and evening visual schedule.

If your child can only tolerate having a toothbrush in their mouth for brief periods try a multi-direction toothbrush which can reach multiple surfaces of your child’s teeth at the same time: Dr Barman’s Superbrush or Curved Toothbrush both available from the Fledglings brochure found on the Fledglings website.

If your child struggles with strong tastes or smells, try an unflavoured toothpaste such as OraNurse 0-3 or OraNurse original.

Sensory Strategies

• If your child is very sensitive, consider using a flannel to wipe the teeth.
• To decrease sensitivity, apply pressure to the teeth and gums. 
• Use a very mild-flavoured toothpaste.
• Promote balance by standing behind your child to secure their body.
• Try an electric toothbrush – the vibration may be calming.
• Try firm massage/squeezes to the head, neck and shoulders in preparation for teeth brushing.

Other Strategies

• Encourage frequent water drinking to remove extra food.
• Try a footstool to help your child reach the basin.
• Facilitate independence in children with fine motor difficulties by using toothpaste in a pump dispenser.
• Play with toothbrushes- use in mixing water or paint with them
• Use a toothbrush to brush a dolls teeth
• With a laminated picture of teeth or a cartoon character with teeth, practice brushing playdough plaque off  the teeth in the picture.
• Brush mum/dad/grandma’s teeth
• Use reward charts, stickers
• Start by playing a game to touch toothbrush on cheeks, then lips, then front tooth, then tongue, then back teeth top, back teeth bottom.

The following applications may be useful to motivate you child to participate in teeth brushing:

1. Heroes of Hygiene
   With four different characters to choose from, Heroes of Hygiene turns oral hygiene into a game that keeps kids engaged for a full two minutes. Kids can play as Captain Molar, Enamel Girl, Max Floss or Pearly Whites. Additionally Heroes of Hygiene helps teach proper brushing techniques and explains to them the importance of visiting the dentist and keeping their teeth clean.
2. BrushyTime
   Brushy Time has separate customizable timers for brushing and rinsing and comes with a clean and simple, classic theme along with a fun pirate theme that kids will love. While the timer counts down, the pirate and his parrot talk to kids to keep them occupied. In addition to the free app there is also an option for a $0.99 upgrade that includes a flower theme.
3. T-Rex Kids Toothbrush Timer
   Got a kid who loves dinosaurs? The T-Rex Toothbrush Timer is just the thing to get them excited about brushing their teeth every day. A cute t-rex shows kids all the areas they need to brush to keep their teeth healthy. As he counts down, different sections of his teeth are highlighted so kids can follow along and brush every surface.
4. Disney Magic Timer
   The Disney Magic Timer has 23 different characters from Disney, Marvel and Star Wars it also gives kids a digital sticker each time they brush for two minutes. It tracks their progress on the calendar and also gives them badges for each milestone they reach. When kids start each session they get to choose an image with their favorite characters that are gradually revealed as they brush, encouraging them to complete the full two minutes of brushing.
5. Brush Up
   Robots and digital stickers make Brush Up a winner with kids. Parents will love the fact that it actually teaches kids how to brush better. Brush Up features Budd, a cute cartoon robot who brushes along with your child. He shows them where and how to brush. The free version includes prizes (stickers), a catchy theme song, and a Magic Mirror that puts your child right there on the screen with Budd. You can also upgrade to the premium version, which has new prizes each month. The Brush Up app also includes real-time reports sent to both you and your child’s dentist, and a Selfie Match game.

Brushing your teeth

Choose a time of day where your child is most calm and when you have time to spend with them. Consider using a visual timetable for the session. Try sitting them on you knee or wrapping them in a blanket to calm them. Allow your child to explore the toothbrush and any other items you are using. If your child becomes upset stop what you are doing and then restart again when they have calmed down. Praise your child for accepting the activities, especially if they put the toothbrush in their mouth.

1. Massage — Give whole face firm massage using baby cream. Work from the inside out e.g. middle of the forehead outwards, bridge of the nose outwards, above the top lip and outwards, from the bottom lip outwards.
2. Tapping — Carry out tapping with two fingers along the upper and lower jaw.
3. Rubbing with fingers inside the mouth — Rub a finger as if it were a toothbrush along the outside of the upper and lower gum ridges, the biting surface of the teeth and the inside surface of the teeth. Move slowly within the child’s tolerance. Repeat this with a washcloth or small cosmetic sponge dipped in different flavours.
4. Time for the toothbrush — Explore the sensation of brushing in all parts of the mouth. Brush the tongue, cheeks and lips. Brushing the sides of the tongue. An electric toothbrush can be used if the child likes and accepts it.

Oral Motor Activities

Try the following activities to increase sensory awareness of the tongue, lips and cheeks:

• Use straws for drinking to increase control of the cheeks and lips. Gradually use thicker liquids and longer straws to increase the amount of lip activity and effort required.
• Explore spicy, tart, or sour foods as these encourage a strong suck e.g. citrus flavours, Cranberry juice combinations, lemonade, and grapefruit juice.
• Ice or cold drinks / foods / toys placed in the fridge or freezer provide strong sensory information around the mouth.
• Food lipstick game- Place enjoyable wet textured food on your finger and place this on the child’s lips. Encourage them to lick it off.
• Encourage the child to provide vibratory stimulation to the tongue, cheeks and lips with a small battery-operated hand vibrator or electric toothbrush.
• Play pat-a-cake, peek-a-boo and other children’s games that incorporate patting, tapping, stroking and other types of tactile and proprioceptive stimulation of the cheeks and
  lips. Tapping can be done directly around the temporomandibular joint to provide better jaw stability. Use music with a clear rhythm and regular tempo as a means for providing tapping and other sensory input to the muscles. Children enjoy singing while you touch and tap the face. It is playful and fun and the emphasis is on the interaction rather than on the stimulation.

Tooth brushing activities

• Provide sensory input with your finger or with the child’s finger as if it were a toothbrush. Rub along the outside of the upper and lower gum ridges, the biting surface of the teeth and the inside surface of the teeth. Proceed slowly and systematically within the child’s tolerance and organisation level.
• Repeat these activities using the edge of a terry cloth washcloth or a NUK toothbrush dipped in water or other flavours.
• Explore the sensation of brushing in all parts of the mouth. Brushing the tongue, cheeks and lips can stimulate muscle tone. An electric toothbrush can be used if the child likes and accepts it.
• Introduce taste on the finger, cloth or toothbrush. Gradually increase the strength of the taste.

Try some deep touch pressure to the face and mouth area

• Face: Many children crave deep-touch input to the outside of the mouth and face, such as firm pressure massages and chewing non food items. Lotion may be used. Apply a small amount of lotion to your hands to help them glide smoothly across the child’s’ skin. With the child sitting on your lap facing away from you, firmly stroke the child’s’ face. Whenever possible, direct the firm pressure in the direction of hair growth. Start at the child’s midline and work out to the sides. Firmly and consistently move your hands across the bridge of the nose; then under the nose, moving down and out across the face; and under the chin; and then from the forehead out to the sides. While the child is in this position, you can easily provide gentle but firm, steady compressions through the child’s shoulders, head or trunk. Some children maybe more sensitive outside of their mouth than inside. Listen to the child and stop if they look uncomfortable.
• Mouth: Heavy pressure across the roof of the mouth usually is calming. Often, the easiest way into a child’s mouth is through a preferred food or dessert. Dip a Nuk brush or a washcloth into the child’s preferred food and provide deep-touch pressure into the roof of the child’s mouth, downward into the centre of the tongue, and eventually into the gums, using a back and forth movement.
• Jaw and Teeth: Deep pressure down into the jaw also is recommended to facilitate biting and jaw action. Biting, using the back molars, can provide resistance and deep proprioceptive input needed to decrease oral defensiveness, promote stability of the jaw and base of the tongue. Encourage your child to play bite and tug with the chewy (to be provided by the OT).

Try some of these activities which involve blowing

• Blow bubbles in the bath water with a piece of tubing/ a straw or blow into a dishpan with a few drops of liquid dish detergent in it. Use plain water if the child tends to suck rather than blow.
• Blow bubbles with commercially available bubbles or home made mixture.
• Blow on whistles. Experiment with different whistles which require a varied seal on the mouth piece, different levels of resistance and variety of grading needed to make the whistle work.
• Blow cotton balls, paper pieces, ping pong balls over the, table top, floor in the water.
• Bumper cars: blow ping pong balls around a tub of water with a straw or long piece of tubing.

Helpful hints

• Wrap your child firmly in a bath towel/blanket/duvet and give them a big bear hug and back rub.
• Massage around your child’s mouth and jaw using a warm face cloth.
• Use an electric toothbrush.
• Be aware that some toothpaste can be very strong in flavour; e.g. some children do not tolerate mint flavours so try strawberry or similar.
• Some children do not like the sensation of toothpaste foaming up in their mouths; in general toothpastes designed to tackle bad breath are less likely to foam.
• Use visual aids and social stories to increase understanding of the task. Go through these aids with your child so that your child knows what is going to happen. Including tooth brushing as part of an evening and morning visual timetable will make the task an expected part of the normal routine.
• Give definite time limits to the task (e.g. “Let’s count to 10. Then we will stop brushing your teeth”). Use a sand timer or other visual aid.
• Use distraction and motivators: Give your child a fidget toy to squeeze during the task. Keep the fidget toy only for teeth brushing

Bathing and showering sensory advice

Washing for personal hygiene and to keep healthy is an essential occupation. Sensory processing difficulties may impact on a child’s ability to have a bath or shower and this can become problematic. Bathing is a sensory experience with different smells, textures, temperatures and sounds that may be over whelming and difficult to process for some children.

Proprioception

• Engage in movement and heavy work prior to having a bath to ‘top up’ their movement sensory system.
• Try putting a bath seat, towel, bathmat in the bath so they don’t move around so much – slipping around in the bath can be unsettling and may mean they can’t process where their body is in space.
• If you are able to, encourage them to sit with their back supported in the bath.
• Are they bathing with siblings and becoming upset? This may be because the movement of others within the bath is unpredictable causing them to be unsure.
• Introduce toys that encourage ‘heavy work’ for the muscles whilst in the bath e.g. pouring water from one container to another, using squeezy bottles.
• Wrap your child in a bath towel after bath or shower time and pretend they are a ‘hotdog’. You can then offer firm, maintained pressure with your hands to put on the ‘ketchup’ and ‘mustard’.

Touch

• Try having a bath with light clothes on, full body swimsuit or their regular swimsuit – they may not like the feel of the water moving against their body.
• You could try starting off the bath wrapped in a towel in the tub and as they feel more comfortable in the water remove the towel slowly and in stages so they become accustomed the to the water.
• Or try a wet towel over your child’s shoulders whilst taking a bath. This can provide calming deep pressure, but also keep their wet hair off their skin.
• Play over the side of the bath to get used to the feel of the water in the tub.
• Consider the bath product you use – do they not like the feel of bubbles or the way the bubble bath makes their skin feel tight? Do they need something more moisturising like an aqueous cream or bath oil (consult your doctor if you child has allergies or skin complaints).
• Try different textures of bath products – bath jelly, bath bombs, bath salts, bubble bath etc. until they find something they like.
• Use firm, touch pressure through the shoulders during bath or shower time.
• Do you use flannels, sponges etc. Do they like the feel of them or not? Can you use a flannel or sponge to encourage them to wash themselves to encourage self-care and calming deep touch feedback? Or do they just need to use their hands as adding another texture in is too much to process?
• Use firm, maintained touch pressure when drying your child.
• If your child does not like being dried, try using a towelling dressing gown or a towel hoodie that they can put on straight from the shower or bath.

Smell

• Consider the scent of the bath product you are using – do they need something fragrance free?
• Have you cleaned the bathroom with frangranced products or had scented candles on – can they tolerate those smells or would it be best to have their bath once this smell has gone.

Sound

• If the sound of water running bothers your child, fill the bath without them in the room.
• If your child likes music try and create a shower playlist together with songs they like. This can help to relax your child and provide predictable noise. Songs can also be used to help signal the end of showering i.e. ‘you only have to stay in the shower for 3 songs’ or ‘hair washing will only last as long as this song’. Visit: help and information.
• Sing bath time songs. Slow, rhythmical music is most calming.
• Try earplugs to minimise bath or shower noises and also prevent water going in their ears.

Routine and Understanding

• Do they have a routine for their bathing e.g same time, same days, part of bed time routine.
• Would they benefit from a visual aid to them know when bath time is coming.
• Use a visual timer or a sand timer to help the child know the end point of the activity.
• Use visuals to support your child’s understanding of the bath or shower steps. Adding personal care activities to visual timetables can make them more predictable.
• Tell your child where you are going to wash so they are ready for your actions.

Showering

• The above points can be considered for showering as well as bathing but there are a couple of other points to consider with showering.
• Look at the angle of the shower head – does it hit there face/ head.
• Check the height of the shower head – does it spray over them in an unpredictable manner.
• Trial different shower heads with different pressure and designs. Children’s shower heads can make showering more fun.
• Can they use the shower head hand held so they have control over where the water goes and when.
• Do they need a face shield/ cap to keep the water off their face.
• Showering can require less movement – does your child prefer this?

Other Things to consider

• If your child struggles with a bath, try a shower or vice-versa. The tactile input from a shower may be more difficult for over-responsive children to cope with and tends to be more alerting so you might want to make this part of the morning routine rather than the wind down bedtime routine. Find the time of day that your child is most able to tolerate bathing tasks.
• What is the temperature of the water – allow them to play over the side of the bath to adjust to the temperature. Encourage them to lower themselves slowly into the bath so that the change in temperature isn’t so shocking to their system.
• Getting out of the shower can sometimes be alerting because of the cold air. Try putting a towel on a radiator, or in the dryer, so that it is warm to put on as soon as your child gets out of the bath/shower.
• If your child struggles with hair washing in the shower try and use a jug to wash their hair.
• Can you alternate strip washes and baths/showers to reduce the amount of times they need to bath.
• If your child is worried about getting water or shampoo in their eyes, try using a bath time visor or letting them wear googles. Keep a dry flannel close by, so that they can wipe their face when required.
• Try and make the bath a fun experience, trial (under close supervision) dimming the lights in the bathroom and adding glow sticks or light up toys to the bath.

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