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DRESSING INDEPENDENTLY AS AN ACTIVITY OF DAILY LIVING


–Triveni Goswami Vernal
Registered Special Educator (A64010)

The skill to independently dress oneself, is another Activity of Daily Living, that requires a lot of coordination between fine motor skills, gross motor skills and even balance. If there is a challenge with even one of these elements, it can create complicate the process of gaining independence in dressing oneself.


Occupational Therapy is one branch of therapeutic intervention that plays a very significant role in honing all the elements (fine motor skills, gross motor skills and balance) required for working on the skill of dressing independently.


The Pre-requisite skills required for Dressing independently, are as follows:
1) FINE MOTOR SKILLS: Finger strength, Hand strength, Ability to grasp and push, Reach out, Pincer Grasp, Eye-hand coordination etc. These skills play an important role in buttoning, zipping and even grasping the fabric.
2) GROSS MOTOR SKILLS: Ability to reach out with arms, Bend at the waist, Squat, Sit Independently, Move one’s limbs, Cross the midline, Bilateral Integration etc.
3) SENSE OF BALANCE: Ability to stand and hold one’s posture, Awareness of one’s body with respect to the surrounding environment etc.

According to the article, “Gross Motor Skills and Getting Dressed” (https://www.yourtherapysource.com/blog1/2020/04/19/gross-motor-skills-and-getting-dressed/), “for complete independence with dressing skills, a task analysis of dressing indicates the child must be able to:
1. reach in all directions
2. rotate the trunk and cross midline
3. bend at the waist
4. maintain sufficient postural control to allow the extremities to complete the skill
5. squat and return to standing
6. maintain balance in sitting and standing while reaching
7. stand on one foot while the other half of the body is moving
8. be aware of where the body parts are in space (ie body awareness)
9. motor plan multiple steps
10. coordinate both sides of the body and the eyes/hands to work together.”

Source of Image: https://www.yourtherapysource.com/blog1/2020/04/19/gross-motor-skills-and-getting-dressed/

One can do several activities at home and outdoors to work on strengthening the child’s fine motor and gross motor skills, through play.

ACTIVITIES AT HOME TO STRENGTHEN FINE MOTOR SKILLS:


1) Tearing and crumpling paper
2) Roll and pinch play dough
3) Insert coins/spoons into thin slots
4) Use tweezers to pick balls of cotton
5) Place clothes pegs on the raised sides of a box
6) Peeling stickers
7) Threading and Beading strings
8) Finger painting
9) Dip sponge in water and squeeze out water
10) Puzzles

ACTIVITIES AT HOME AND OUTDOORS TO STRENGTHEN GROSS MOTOR SKILLS:


1) Throw and catch balls
2) Dancing
3) Hop Scotch
4) Jumping
5) Obstacle course
6) Climbing a ladder
7) Pretend Play
8) Foot ball
9) Walking on a low plank /board for balance
10) Cycling

Thus, we see that Dressing Independently comprises of establishing a smooth coordination amongst several components and we must ensure that each of these components are individually worked upon, to help the child achieve a semblance of independence. Apart from this, several kinds of adaptations can also be made to the clothes, to help the individual dress independently. Adaptations may include using Velcro instead of buttons/zips, using a coloured, and raised piece of fabric attached to the inner side of a shirt/t shirt, such that the individual can make out the difference between the front and back of the clothing etc. The ultimate aim for us, is to create accessible and adaptive clothing for the child, so as to make the process of dressing, stress free and happy for them, thus providing them a sense of confidence and independence.

RESOURCES:
https://www.niepid.nic.in/Dressing.pdf
https://playmatters.org.au/blog/learning-dressing-skills-through-play
https://www.yourtherapysource.com/blog1/2016/09/27/5-gross-motor-activities-help-dressing-skills/
https://www.yourtherapysource.com/blog1/2020/04/19/gross-motor-skills-and-getting-dressed/
https://otplan.com/activity/buttoning-board/
https://www.occupationaltherapy.com.au/10-ot-tips-for-buttons-and-zippers/
https://www.theottoolbox.com/teaching-kids-how-to-button-self-help-skills/
https://www.communityservices.act.gov.au/__data/assets/pdf_file/0020/1059203/Handout_CDS-Dressing-Skills_FA.pdf
https://www.swft.nhs.uk/application/files/4614/5995/2570/dressing_skills.pdf
https://www.swft.nhs.uk/application/files/4614/5995/2570/dressing_skills.pdf


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Author Triveni Goswami Vernal

Triveni Goswami Vernal is an Autism advocate, registered Special Educator (CRR A64010) and an Independent Researcher. Her areas of interest include Autism, Disability Rights, Gender, Art and Northeast studies. She is a mum to an 11 year old on the Autism Spectrum.

Creative representation for this blog is done by our extremely talented CreativeSaathi associate Kabir Vernal

“Flowers in a Purple Vase”
Acrylic Painting on canvas
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Toilet training and Autism

TOILET TRAINING AND AUTISM
-TRIVENI GOSWAMI VERNAL
Registered Special Educator (A64010)



Toilet Training is one of the most important Activities of Daily Living that all parents and caregivers, work towards. Neurotypical children, usually get toilet trained by 3- 4 years. It is an arduous process for all children, but the process becomes more complex for children on the Autism Spectrum, who may require a wide variety of visual supports to aid their learning process.


As with all other ADLs, Toilet Training also has to be broken down into small, doable components and a strict visual schedule has to be maintained and followed for atleast two months, till it becomes a habit for the child.


TASK ANALYSIS OF TOILET TRAINING:
1) Enter the Bathroom
2) Pull down pant /pull up dress
3) Pull down underwear
4) Sit on the Toilet seat
5) Do the job
6) Use a Spray or Mug of water to clean themselves
7) Flush the Toilet
8) Pull up underwear
9) Pull up pant /Pull down dress
10) Open the tap of the sink.
11) Take soap from dispenser /bar of soap
12) Wash hands: Scrub hands with water and soap
13) Close the tap
14) Dry their hands with a towel

Source of image: https://in.pinterest.com/pin/772437773558037361/

Please note: Instead of the visual of the use of Toilet Paper & Wipe, you can insert a clipart of a Mug or a Toilet spray, instead, depending on what the child uses.


One cannot teach all these steps at once. Initially the focus can only be on taking the child to the toilet every half an hour, like clockwork. Make the child drink enough water and take the child to the toilet. One can increase the time frame between toilet visits, incrementally over time.


There are a few important points to be remembered while Toilet Training. If the child is still wearing diapers, then training them while they have moved to wearing pull ups/diaper pants, is a good option, as they mimic, wearing an underwear. This case often arises, when the child is sent to a school or a day care, that refuses to take in a child, unless the child is toilet trained. The option, then, is to send the child in diapers and hope that the support staff in the school, would take the child to the toilet at regular intervals, even if the child is unable to express his/her need.


In case the child stays at home, and there is a caregiver/parent with the child at all times, then the child can be off diapers and made to wear an underwear and their regular clothing. It is important to teach the child to wear an underwear, beneath their regular clothing from their early days, because as they grow older, it becomes far more difficult to teach the children the importance of wearing an undergarment.


EXAMPLE OF A VISUAL SCHEDULE
(One can make it as detailed, or with as little information, as feasible)

Every time the child goes to the Toilet and is able to use the Toilet for his toileting needs, his /her behaviour has to be Positively Reinforced (it may initially be a tangible reinforcer like a toy/food or something the child really likes and care has to be taken that the reinforcer is only limited for Toilet Training and not used elsewhere. But later on, one can switch to non-tangible reinforcers only, such as Praise, Hugs, Giving lots of Attention etc). The child can be taught to place a mark on the schedule, when the job is done in the toilet. That also provides a sense of achievement and ownership to the child.



FIRST, THEN, NEXT VISUAL

Source: https://www.autism.net/resources/visual-gallery_/t23054/s23699-first-then-board

Printable Resource:
https://adayinourshoes.com/wp-content/uploads/2017/10/first_next_then_boards.pdf

With a First, Then & Next visual, a few steps can be taught at one go, to the child. For example, Feel Pee Pee/Potty, Sit on the Toilet & do the job, Get a Reward. Or one can also use it to teach the first few steps in the Task Analysis of Toilet Training. The possibilities are endless.



CHALLENGES THAT A CHILD MAY EXPERIENCE DURING TOILET TRAINING AND THEREAFTER:


So, while the process of Toilet Training is quite arduous in itself, sometimes there are associated challenges that might make the process even more complex. Some of them are as follows:

a) Vestibular Sensory Issues: The Vestibular sensory system deals with our sense of balance and movement. It controls the working of our muscles and also our reflexes. An Over-Responsive Vestibular system or Vestibular Hypersensitivity can make a child fearful of sitting on the toilet. An over-responsive vestibular system can make a child fearful or anxious with uneven and unstable surfaces and the child can develop gravitational anxiety, a fear of their feet leaving the ground. The Middletown Centre for Autism, has listed down a variety of sensory strategies to work on a child’s fear of sitting on the toilet seat (https://sensory-processing.middletownautism.com/sensory-strategies/strategies-according-to-sense/vestibular/over-responsive/).

b) Constipation: A number of children on the Autism Spectrum also have digestive issues, like Constipation. Besides feeding them a fibre rich diet, a low foot stool can also be used at the base of the toilet, for their feet to be placed on and to help exert pressure.

c) Interoception: Interoception refers to a sensory system that provides an individual, the information about one’s internal bodily processes such as Hunger, Thirst, Awareness of when the Bladder is full, and when they need to use the toilet etc. So, even when a child may be completely toilet trained, they might still have accidents as they may be so engrossed in an activity of their choice, that they miss out on the signals provided by the body. The following website, https://www.education.sa.gov.au/sites/default/files/interoception-301-activity-guide.pdf , has a list of activities that can help improve the sense of Interoception in an individual. Teaching the child to be more aware of his/her bodily sensations, like tightening of the muscles in the stomach, or increasing pressure /pain in the stomach or the need to run to the toilet, are some important strategies.

The article, “Four Strategies to Improve Toileting through Interoception” on the website Fun and Function, https://funandfunction.com/blog/four-strategies-to-improve-toileting-through-interoception, includes doable and easy strategies that can help the child understand his/her internal bodily processes, better.

MY JOURNEY OF TOILET TRAINING MY SON:
Due to several disruptions earlier, my son was completely toilet trained only when he turned 8. It took strict scheduling for atleast two months, till he became habituated to using the toilet independently, without the need of a reinforcer. Although it has been three years since he has become independent in his toileting skills, accidents do occur, although rarely. Last year, after a series of accidents, I began to explore and look up articles on Interoception and Toileting. The more I read about it, the more I realized how important it is to keep working on this sense, to improve upon the child’s bodily awareness.

Being able to independently use the toilet, is one of the most important life skills, a child can ever have. But one must not lose heart, if the process takes longer than usual. One must always remember, that a child on the Autism spectrum, is battling with his or her own battles, that may not be visible to others, and that may complicate the process of Toilet Training, further. As a caregiver or parent, our aim should be to be aware of various associated factors that may be impacting the child’s toilet training and work on those aspects, diligently, till a pattern can be established for the child.

Printable Resources on Toilet Training:
https://www.andnextcomesl.com/2018/06/free-potty-training-visual-schedules-for-kids.html
https://autismlittlelearners.com/free-toileting-sequence/
https://www.withinmetherapy.com/post/potty-training-tips-for-children-with-autism
https://raisingchildren.net.au/autism/health-wellbeing/toileting-hygiene/toilet-training-autism#:~:text=Visual%20supports%20and%20toilet%20training,-Visual%20cues%20and&text=Stick%20the%20schedule%20on%20a,way%2C%20training%20will%20be%20consistent.
https://www.autismspeaks.org/sites/default/files/2018-08/Toilet%20Training%20Guide.pdf
https://www.marcus.org/autism-resources/autism-tips-and-resources/tips-for-toilet-training
https://www.milestones.org/resources/tool-kits/toilet-training-tool-kit
https://beaminghealth.com/article/the-complete-guide-to-potty-train-your-autistic-child
https://autismlittlelearners.com/free-toileting-sequence/

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Author Triveni Goswami Vernal

Triveni Goswami Vernal is an Autism advocate, registered Special Educator (CRR A64010) and an Independent Researcher. Her areas of interest include Autism, Disability Rights, Gender, Art and Northeast studies. She is a mum to an 11 year old on the Autism Spectrum.

“Aquarium”, Acrylic Painting

Creative representation for this blog is done by our extremely talented CreativeSaathi associate Kabir Vernal

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ACTIVITIES OF DAILY LIVING (ADL) AND AUTISM


-Triveni Goswami Vernal
Registered Special Educator (A64010)


Activities of Daily Living or Life Skills are activities that are routinely followed by individuals, that help them be independent in life. For an individual with various challenges, these daily activities can prove to be cumbersome. And hence, they need to be broken down into small components that can be taught individually till it is mastered, before the entire activity is taught and becomes second nature to them.

Activities of Daily Living include:

1) Self-care and Hygiene: Bathing and drying themselves after a bath, Brushing Teeth, Clipping Nails, Getting dressed etc
2) Sleeping: Sleeping on their own
3) Toileting: Using the Toilet independently and cleaning up after themselves
4) Meal Times: Preparing a meal, eating independently, washing dishes etc

Mastering the various ADLs, is the end goal for almost everyone on the Autism Spectrum. The core idea is to keep working on these skills across the years, such that the individual can become independent in those skills, and not be forever dependent on caregivers, all their lives.


According to the website https://thespectrum.org.au/autism-strategy/autism-strategy-activities-daily-living/, Daily Living activities are important for the following reasons:

• “Independence: if you are able to look after yourself by undertaking these key activities of living you are more likely to be able to live safely and independently as an adult.
• Self-esteem: self-reliance helps with self-esteem, it feels good to be able to look after yourself without needing help.
• Less reliant on others: as with the above two points, it’s an excellent goal to be able to function on your own without needing assistance from other people if possible.
• Skills for life: these daily living skills are tasks that everyone needs to undertake every day throughout their life. If you can learn to undertake them yourself early, it will make life a lot easier and improve your quality of life.”

Each activity that we perform on a daily basis, is often taken for granted by us, because it takes place so naturally that we do not spend time analysing how many small components make up one particular task. For example, the activity of Brushing Teeth might seem a simple task, but when you break down the steps, you realize how complex the activity is, in reality.


In Special Education, a strategy to break down the activity into the small steps, is called Task Analysis. So, a Task Analysis of Brushing Teeth brings up the following steps:
1) Take the Toothbrush and keep it down on a surface.
2) Take the Toothpaste tube with one hand.
3) Twist the cap of the Toothpaste tube with the other hand and open it.
4) Remove the cap and keep it on a surface.
5) Squeeze the toothpaste tube, just enough to place a small amount of toothpaste on to the toothbrush.
6) Place the toothbrush on a surface.
7) Twist the cap and close the toothpaste tube. Put it back to its place.
8) Pick up the Toothbrush with the paste on its bristles.
9) Open the tap in the sink and wet the toothbrush bristles.
10) Close the tap in the sink and brush the teeth, in various motions.
11) Once done, open the tap, and clean the bristles.
12) Replace the brush back to its place.
Visual for Brushing Teeth



Source: https://blog.difflearn.com/2018/03/15/simplifying-morning-routine/
A Printable Visual for Brushing Teeth: https://www.kidsability.ca/uploads/Autism%20Services/Tooth%20Brushing%20Visual%20Schedule%20Printable%20Resource.pdf
One can choose to be as detailed or keep the steps short and concise, depending on the ability of the individual. The idea is to break the activity into small steps that are doable and can be taught in a simple and stress-free manner.
Another strategy of Special Education that can be applied while teaching the steps in a Task Analysis are BACKWARD CHAINING or FORWARD CHAINING.


Backward Chaining refers to a technique where the last step of the task is taught first, and once that is mastered, one can teach the earlier steps. So, for example, for Brushing Teeth, the individual will be first taught to do the last step, that is washing the bristles of the brush under the tap water and keeping it back in its place, while the rest of the steps will be done by the caregiver. Once that is mastered and can be done independently, the step next to last, that is brushing the teeth, will be taught.
In contrast, in Forward Chaining, the first step of the task is taught first, till it is mastered, and then one moves on to the next step. For example, in Brushing Teeth, the first step of taking the toothbrush from its place and then opening the cap of the toothpaste tube will be taught first, while the rest of the steps will be done by the caregiver, till the time the first step is mastered and then they will move on to the next step.
The strategy of Chaining (whether Forward or Backward) is adopted so that it does not overwhelm the individual who is being taught. The idea is to provide handholding and scaffolding for the individual to learn the task, at his or her own pace, without being rushed.
This was just a small example, but the idea of breaking down a task into smaller components and providing a visual for it, is very significant. Visuals help the individual remember the steps pictorially. Most individuals on the Autism Spectrum are visual learners and often struggle with Executive Function and Self- Regulation.
According to the Centre on the Developing Child, Harvard University, “Executive function and self-regulation skills are the mental processes that enable us to plan, focus attention, remember instructions, and juggle multiple tasks successfully. Just as an air traffic control system at a busy airport safely manages the arrivals and departures of many aircraft on multiple runways, the brain needs this skill set to filter distractions, prioritize tasks, set and achieve goals, and control impulses” (https://developingchild.harvard.edu/science/key-concepts/executive-function/).
By breaking down the task into doable, small components and representing those tasks, visually, the individual is helped in planning, remembering the various steps involved, paying attention to the task at hand and implementing the various steps, to fruition.
As a caregiver, our aim is to make the process of learning more accessible and stress-free for the individual with challenges, with a final goal, towards their independence. Only if we create the right environment to facilitate their learning and engage them proactively in the learning process, can they progress towards the final goal.
Free resources on Visual schedules for various ADLs:
https://drive.google.com/file/d/1uWXSRNPOTC0p0FRKZulgEZiR2LICQHRz/view
http://www.shesalwayswrite.com/2014/05/autism-resource-potty-training-visual.html
http://autismeducators.com/browse-worktasks/free/FREE-Bathroom-Visual-Schedule-For-Boys-AutismEducators
https://www.naturalbeachliving.com/daily-visual-schedule/
https://adayinourshoes.com/free-printable-visual-schedules-for-home-and-daily-routines/
https://www.nhsggc.org.uk/kids/resources/ot-activityinformation-sheets/visual-aids-for-learning-bathing-independently-girl/
https://www.teacherspayteachers.com/Product/Bathroom-Routine-1992783
https://learningforapurpose.com/wp-content/uploads/woocommerce_uploads/2021/01/Taking-a-Shower-Toolkit-Bundle-2-rpdsnz.pdf
https://www.kidsability.ca/uploads/Autism%20Services/Dressing%20Visual%20Schedule%20Printable%20Resource.pdf
https://www.andnextcomesl.com/2018/01/free-visual-schedule-printables.html
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Author Triveni Goswami Vernal

Triveni Goswami Vernal is an Autism advocate, registered Special Educator (CRR A64010) and an Independent Researcher. Her areas of interest include Autism, Disability Rights, Gender, Art and Northeast studies. She is a mum to an 11 year old on the Autism Spectrum.

“Yachts”
Acrylic paints and Texture paste on canvas

Creative representation for this blog is done by our extremely talented CreativeSaathi associate Kabir Vernal

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Teaching Cooking activities for kids with Autism

A video blog by Pinki Kumar on Teaching Cooking activities for kids with Autism.

Author Pinki Kumar

Pinki is a special educator, play therapist and a mother of a neurodivergent kid. She has a YouTube channel Play and learn to teach different methods and strategies. These videos are a great resource for the parents to help their child learn various skills.

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Prerequisite for Speech therapy at home: holistic healing of chakras

A video blog by Ramya @simpleathomeclub on ADL activities which are the prerequisite for Speech therapy at home. A holistic approach of healing of chakras, helps in calming and sleep inducing.

Author Ramya

I am named Ramya, would love to be called mom from my 13 year old son.  Certified in various streams and last year remedial too.
@simplyathome YouTube channel was created to have my sanity and to support other caregivers of kids in spectrum who are aware of what needs to be done, but stagnant like I have been on the “how to’s”  break down the process.
This is my small way to give back to community by sharing all that I attempt at home. Home is where values embed and home is the first school for each of us.