1. Hand washing
- Lack of understanding of why their hands need to be washed when there is no visible dirt.
- Dislike of the sensation of water running over their hands.
- Aversion to the smell of soap
- Identifying the risk of using very hot water.
- Dislike/fear of the noise of hand dryers in public toilets.
Additional note about ear defenders:
Ear defenders should be used as part of a desensitisation programme. The child/young person can wear them to block out an unpleasant noise but should be prompted to remove them for the last 5 seconds of the noise and then for gradually longer periods until they can fully tolerate the noise.
- Provide visual instructions to teach and prompt the sequential steps involved in hand washing. This could be displayed at the basin at home or in school, and a portable visual system used for public toilets.Photograph of objects set out in sequence e.g. soap, basin, towel.
Instructions using symbols:
- Add hand washing to a visual schedule at the relevant times e.g. after using the toilet, before eating, after playing in the garden.
- Explain the importance of hand washing in a way which is meaningful for the individual e.g. to keep hands clean, to remove germs, to prevent illness. This can be done through a social narrative or the child/young person could research it themselves.
- If the individual is tactile sensitive to the sensation of water running over their hands, teach them to fill the basin and soak hands instead. If this is still not tolerable, alternatives include using a facecloth or baby wipe to wash hands, or using a sanitising hand gel.
- Provide soaps with minimal or no smell if the child or young person cannot tolerate strong scents.
- Teach the child/young person to dry their hands with hand towels in public toilets if they dislike the hand dryer. Toilet roll may have to be used if hand towels are not available. They may also need to be taught to put their hands over ears or to use ear defenders if they cannot tolerate the noise of other people using the dryers. Hand dryer – social narrative
(an issue with toileting may be related to maturity, proprioceptive, tactile and gross motor difficulties, below are some general strategies)
- Child/young person does not register the need to go to the toilet i.e. does not sense that bowel or bladder is full.
- Child/young person does not sense when wet or soiled.
- Child/young person has a fear of using the toilet/is aversive to sitting on the toilet.
- Child/young person will only pee/poo in nappy or pull-up.
- Child/young person does not fully empty bowel or bladder when using the toilet.
- Child/young person forgets steps in the sequence e.g. does not wipe bottom before pulling up pants; forgets to pull down pants before using toilet.
- Child/young person cannot independently manage fastenings on trousers.
- The first five challenges listed are likely to be physiological or psychological barriers to using the toilet. These will need to be assessed and addressed by a qualified professional before teaching independence in using the toilet. Continence nurses, health visitors, paediatricians and occupational therapists will be able to assess and offer support on these issues.
- Place toilet symbol on child’s schedule at regular times to establish pattern of going to the toilet.
- Give child/young person visual card to request when they need to go to the toilet.
- Be alert to signs that the child/young person needs to go to the toilet and direct them using visual symbols so they associate the symbol with the toilet.
- Provide a visual activity system so child/young person can follow step-by-step sequence of using the toilet. Place this on toilet door, beside toilet or have a portable visual system.
Visual instructions using symbols – Going to the toilet symbols
Written instructions – How to use the toilet word instructions
Visual instructions for boys – Aim for the toilet
- Ensure same visual system is used across all settings.
- Dress child/young person in clothing which is easily managed e.g. elasticated trousers, Velcro fastenings.
- If child/young person will only pee or poo in nappy/pull-up, direct them to stand beside toilet, or sit on toilet, when doing pees or poos but still wearing nappy or pull-up. The nappy/pull-up can then be removed at a later date when they have become more familiar with sitting on the toilet.
- Explain why people use the toilet, using resources which are meaningful for the child.
- Toileting for teenagers
- Lack of understanding why it is necessary to bath or shower, especially if there is no visible dirt.
- Dislike of the sensation of water running over the skin, especially in the shower.
- Dislike of the smells of the soaps, body washes and shampoos.
- Omitting steps in the sequence e.g. not washing all body parts, not rinsing off soap.
- Unsure of how long to stay in the bath or shower.
- Bathing or showering too frequently or staying in bath/shower too long.
- Add bath/shower to the individual’s daily or weekly schedule to prepare him/her for when it will happen.
- Set up a visual timer (e.g. sand timer, stop watch, alarm on phone) to indicate how long to stay in bath/shower.
- Provide a set of visual instructions of how to bath/shower e.g. listing all body parts to be washed. Laminate this so it can be placed on the wall in the shower or beside the bath.
Photograph of setting objects out in sequence:
Visual instructions using symbols:
- Explain the importance of bathing or showering in a way that is meaningful for the child/young person
- Use soaps, shower gels, shampoos etc which have no or minimal scent. Alternatively, find a scent which the individual really likes as this may provide a motivation to bath/shower.
- Children/young people who like deep pressure input to the skin may prefer to wash with a harsher texture e.g. body brush, loofah. This can help to keep them calm and regulated in the bath or shower.
- If the child or young person dislikes the sensation of the water, increase tolerance by very gradually increasing the time spent in the bath or shower. It might start with 30 seconds and then slowly increase from there.
- If the child/young person cannot tolerate a bath or shower, allow them to wash at a basin, then gradually move a portable basin closer to the bath or shower and eventually place the basin in the bath or shower. Encourage them then to use the bath or shower for a short time (e.g. 30 seconds) and then gradually increase duration.
- Fear/avoidance of new task.
- Lack of understanding of why shaving is necessary.
- May not have observed anyone else shaving.
- Dislike of the tactile input from the shaving foam, razor and water.
- Fear of cutting himself.
- Dislike of the smell of the shaving foam.
- Dislike of the noise and tactile input from an electric razor.
- Offer choice between wet shave or using electric razor.
- For wet shaving, photograph of objects set out in sequence i.e. shaving foam, razor, basin/facecloth.
- For wet shaving, instructions using photographs, symbols and/or written instructions.
- An electric razor is usually the best option if there are a lot of sensory sensitivities. It also reduces the risk of the young person cutting himself.
- Ensure young person has opportunity to observe male family members or friends shaving. This should happen as early as possible so the task is very familiar when the times comes for him to shave.
- Provide diagram of a face to serve as a visual prompt showing all parts which need to be shaved.
- Use visual timer to show how long to shave for, especially when using an electric razor.
- Explain why it is necessary to shave in a way which he will understand.
- Shaving video:
5. Washing hair
- Lack of understanding of why it is necessary to wash hair, especially as there is usually no visible dirt.
- Dislike/avoidance of tactile input e.g. another person touching his/her hair, sensation of water running over face and neck.
- Dislike of the smell of the shampoo.
- Forgets to rinse out shampoo or does not rinse fully.
- Uses too much or too little shampoo.
- Allow child/young person to wash hair independently as this gives them a sense of control over the task. They can control how much pressure is used when shampooing and rinsing and they are in control of when water is poured over their head. This removes the fear of unpredictability when someone else is shampooing and rinsing their hair. Encourage them to wash their hair independently from as early an age as possible.
- Visual instructions will help to promote independence
Photograph of objects set out in sequence i.e. shampoo, jug of water, towel.
Visual instructions using photographs, symbols and words – washing hair symbols
- Allow child/young person to choose preferred method of rinsing shampoo e.g. jug of water poured over head, shower, repeatedly rinsing with wet facecloth. Using a facecloth means that deep pressure can be applied which may help the child/young person to remain calm.
- Use a visual timer to show them how long the task will last. A visual timer could also be used when they are washing their hair independently to indicate how long to shampoo and rinse.
- Encourage child/young person to use mirror to check that all shampoo is rinsed out.
- Use shampoo with no or minimal scent, or find a scent which the child/young person really likes. Allow them to select their own shampoo in the shop and to check the scents.
- Use a social narrative to explain the importance of keeping hair clean.
6. Brushing teeth
- Limited understanding of why it is important to brush teeth.
- Parents/carers will have brushed the child’s teeth in the early years so child/young person is not used to carrying out the task independently.
- Child/young person may be sensitive to the tactile sensation of teeth being brushed and may find it painful.
- Child/young person may dislike the taste of toothpaste.
- Unsure how long task should last i.e. may spend too much or too little time brushing teeth.
- Child/young person may lack adequate hand strength to brush teeth properly and does not use adequate pressure when brushing.
- Include teeth brushing on schedule so it becomes part of the consistent daily routine for the child/young person.
Photograph of objects set out in sequence – brushing teeth instructions
Visual instructions using photographs/ words – how to brush my teeth
Visual instructions using symbols:
- Brushing teeth symbols
- Brushing teeth visual instructions 1
- Brushing teeth visual instructions 2
- Daily Routine Cards
- Younger children and those with significant motor difficulties will need a parent/carer to brush their teeth for them to ensure it is done thoroughly. However, the parent/carer can still give the child a turn to brush their own teeth before or after it has been done by the carer. This then begins to foster greater independence so the individual is ready to do it independently when appropriate.
- Explain the purpose of brushing teeth through the use of a social narrative.
- Encourage child/young person to research importance of brushing teeth if he/she is able to do so.
- Ask dentist for any relevant resources explaining the importance of brushing teeth.
- Take child/young person to shop to select own toothbrush as this may improve motivation.
- Try different types of toothbrushes e.g. hard/soft bristles, electric, musical.
- Try different pressures when brushing child’s teeth. Some children who are tactile sensitive will prefer firmer pressure as this is often more tolerable, and sometimes calming. Others may prefer more gentle pressure.
- An electric toothbrush is useful for a child/young person who may not be brushing with enough strength/pressure.
- Other flavours of toothpaste are available as an alternative to mint, or flavourless toothpaste is also available.
- Use a visual timer to show how long teeth should be brushed. An alternative is to let the child/young person to listen to a favourite song when brushing teeth and when the song is finished, they can stop brushing. This is often a useful distractor and motivator.
7. Blowing nose
- Child/young person may not register sensation of runny nose so does not know to wipe or blow nose.
- Child/young person may not tolerate sensation of tissue.
- Child/young person may dislike the tactile input of another person touching his/her nose.
- Child/young person may not understand why a tissue or hankie should be used to wipe nose.
- Child/young person may not have physical ability to properly blow nose.
- Use visual prompt card to remind child/young person to clean their nose.
Visual instructions using symbols
- Encourage child to wipe nose independently.
- Give child/young person choice between tissue or cotton hankie to wipe nose.
- Use social narrative to explain why nose should be cleaned.
8. Cleaning ears
- Child/young person cannot see into their own ears and so do not realise that they need to be cleaned.
- Child/young person may not see the purpose in cleaning their ears.
- Sensory sensitivities may cause the individual to dislike/avoid anything touching their ears.
- Child/young person may be at risk of pushing cotton bud too far into ear and causing damage, so requires adult assistance.
- Add ‘cleaning ears’ into a consistent personal care schedule.
- Provide a social narrative clearly explaining why it is important to keep ears clean.
- Allow child/young person to clean their own ears so the tactile input is predictable and they can control the amount of pressure used.
- Teach how to clean ears using demonstration on your own ears and /or photographs.
Visual instructions and activity system for self-care:
- Visual instructions and activity system self care
- Visual instructions and activity system self care 2