OT Sensory Strategies to use in Developing Self-Care Skills

Judy Benz Duncan, Occupational Therapist

Sensory sensitivity can lead to a variety of difficulties in children and young adults in developing their independence with daily self care and life skills.  

Sensory processing and integration deficits are often used to describe how your child’s brain and body reacts to different sensations and situations. These sensory issues refer to the way a sensation is felt or experienced, and in turn, are organized and interpreted by the brain. Having issues with sensory sensitivity levels are typically found to be at the root of sensory processing issues and impact how a child learns, grows, develops, and participates in basic routine self-care activities.  

Sensory Threshold Impacts Self Care Participation

For a child with sensory integration and processing system, their sensory threshold, in basic terms, describes just how much sensory information your child can tolerate before they react in one way or another. Some children react to a clothing tag touching their skin, other children seek out loud chaotic situations.

Every child is different in how they interpret and experience their world. Understanding your child’s sensory threshold is a beginning step in helping them manage living in their normal surroundings, being able to develop greater tolerance for new situations and social activities, while working to grow and become more independent in their daily self-care routines.

Performing Self-Help and Self-Care Tasks Normal Part of Life

Self-help skills for children can range from the daily living skills of bathing, dressing, and grooming, to cleaning their rooms, fixing simple meals and snacks, and helping around the house.

The ability to perform these routine daily tasks are often taken for granted, and expected as a “normal” part of growing up. All these skills require the development, growth and learning involving very precise and complex neurological processes.

For neuro-typical children, the development of these skills takes place through normal patterns of development which are usually experienced through the everyday play and work of children.

For children with sensory integrative deficits, or children with developmental delays, routine developmental milestones can involve monumental challenges.

Adapting Self-Care and Self-Help Learning Opportunities

Most all tasks and activities can be broken down into smaller manageable parts for your child. Tools and utensils can be adapted and modified for small hands or hands that need help with grasp and coordination. Working with your child’s providers, who know you and your child, can help you develop a plan that works.

Giving your child learning opportunities in self-help, self-care, and basic home tasks, gives them the world in growth experiences, and learning, as well as fosters the development of self-esteem, pride, and feelings of independence!

Sensory Strategies in Self-Care Tasks

The following strategies may help in developing increased participation and independence in routine self-care and self-help tasks.

Give lots and lots of opportunities throughout the day!

Dressing:

Being able to get dressed independently is an important childhood milestone but it takes lots of practice, experience, and play to get there.

If you are working on dressing skills with your child, taking the time to play some fun, and educational, dressing games, may help your child make the connections and motor planning skills needed to succeed with self dressing.

There are several games that help with learning self-help dressing skills. Pretend play is a great way to incorporate dressing related activities and games.

Use comfortable clothes that you know your child will wear now

Consider the type of fabric – try to choose those materials that you know your child will tolerate

Look at the length of sleeves – will they tolerate no sleeves, ½ sleeves, full sleeves? Try to pre-plan and choose those types of clothing you know your child will accept

Can your child tolerate labels? If not cut them out, or look for clothing that are “tag free”

Can your child tolerate seam lines in their clothes? Look for sensory friendly clothes and undergarments, looser fit so that the seam lines are less noticeable, or seamless undergarments

Try washing and drying all your child’s clothing in unscented detergents and softeners

Try letting them dress in front of a mirror to provide visual cues for body awareness, sequencing, “how they look”

Be aware of other visual or auditory noises (tv, radio, fans, bright lights) in the room which may be distracting or overwhelming

Play “Simon Says” game where you focus on pointing to and naming body parts (helps in letting your child become more aware of their body, where to look when you say “put your arm in the shirt sleeve,” or “put one foot at a time into your underwear.”)

Play “Body Part Identification” in the bath or during wash-up time (“can you wiggle your toes, can you wiggle only your big toe, can you touch each finger to your thumb, can you reach around to touch your low back, can you wash the bubbles off your arm, can you put your hands on your waist,” and so on – let your child imitate you if they need the cues for full understanding); Use a stuffed animal in the bath to play this game with as well!

Practice dressing and undressing a doll or stuffed animal – you can make up a story about them needing to change their clothes to be ready for school, or bed, or because they got their clothes dirty and need to change. Pretend play that they are the parent, or teacher, or doctor, etc, during this pretend play game.

Work on undressing as fast as they can – time them and keep a graph or chart of their progress. You can start with just taking off their shoes and socks, to getting totally undressed. It is much easier to work on undressing first as it involves more basic and simpler skills than dressing and having success with this process will give them greater confidence while they develop their skill base.

Include toys and items in play time where they are working on pulling apart, pushing together, like they may encounter with Velcro straps and other types of clothing fasteners – try magnetic toys, basic dressing training boards, pop-beads, Lego’s or Duplo blocks, strips of Velcro to pull / “tear” apart, big bubble wrap to squish and pop, and so on

Pretend play dressing box – spend some play time in pretend play with capes, hats, scarves, slip on shoes, loose fitting pull-over shirts, loose elastic waist pants, easy on jackets, etc, old costumes; take some pictures of the different looks and outfits your child tries on!

“Hide,” or partially hide, small stuffed animals, colorful strips of fabric or wide ribbon, in your child’s pocket, waist band, sticking out of their sock or shoe, inside their shirt, etc., and see how fast they can find and pull out. Talk about what they found, the color, where it was, and praise how quickly they were able to find! Can they hide these items on you? If they will keep their eyes shut while you hide that’s great – they will still feel the tactile / sensory input as you do reach into a pocket or under their shirt. If they cannot tolerate on themselves, try playing the game hiding the items on a dressed stuffed animal friend.

Cut slits through a heavy piece of cardboard – take a handful of large buttons and have your child push each one through the slit to come out the other side – see how fast they can get 5 or 10 through the slits. See if they can hold and push with thumb and 2 fingers, or if they need you to help, get the button started into the slit and then let them finish pushing it through. Give the help they need and let them do the rest! When the cardboard activity becomes too easy, move it up to using a heavy piece of fabric or actual piece of clothing (much harder to manage and control).

Place a hula hoop on the ground – have your child step into it, reach down and then bring up and over their head, to play down in front of them to continue with action all the way across the room. You can add strips of fabric around the hoop so your child feels the cloth as they pull the hoop up, over, and off their head.

Take an adult sized long-sleeved shirt or jacket, seal the cuffs with elastic bands and then hide small soft and stuffed toys down each sleeve.  Have your child reach into the sleeve and pull out each toy one at a time.

Try BIG lacing cards, Connect Four game, play-dough fun, dressing toys and sets, sticker books – look around your house and in the toy box to see what you can find, re-purpose it’s use, and above all, turn into play-time learning!

Personal Hygiene / Bathing:

Try to incorporate bathing into a play activity, like using floating toys and bubbles and/or colored soaps, water beads, kid-safe tub markers

Consider using bathtub adaptive equipment that may make the task easier or let your child feel safer (grab bar, low tub seat or even using a laundry basket to sit in while in the tub)

Use non-perfumed, non-scented soaps, shampoos

Be aware of bathroom lighting levels – bright glaring lights may be too much to handle

Minimize noises (run the bath water prior to entering the bathroom, use towels to help muffle the sound, wrap metal faucets with faucet cover, and so on)

Use consistent deep pressure when shampooing or drying them off with a towel

Before their bath time, try activities that provide deep touch sensory input activities

If your child dislikes having his face or body washed, encourage them to wash himself as that may reduce any defensive reactions

Use a large sponge or loofah sponge if tolerated, for washing and scrubbing; use with pressure

If using a shower, try to use a long-handled shower hose and let the child help to control the direction and force of the water

Try to wrap in a large towel as soon as leaving the water to avoid exposure of the wet skin to the air and to keep as warm and comfortable as possible

Use the sink to wash if the tub/shower is not tolerated

Try letting your child wash their toys or dolls to encourage interaction with the water, soaps

Discover if your child responds to praise for efforts and success, or if keeping the whole process structured and routine without any change in expected reaction works best for you and your child

Depending on your child’s sensory needs, use unscented soaps, soft towels, check temperature of water, dim the lighting, muffle sounds with towels or padding, keep the ceiling fan off if it bothers them

Make a visual card or booklet to show the bathroom, tub and shower, faucet, sink for washing hands, towels, and talk about the sequence of what will happen while they are washing up

Hair Care:

Make a visual card or booklet to show the hair salon, barbershop, or kids having their hair cut or brushed, and talk about the sequence of what will happen

Provide a toy to play with, sing a song with them, blow bubbles, and so on while they are having hair brushed or cut to help distract and keep any anxiety levels down

Discover if your child responds to praise for efforts and success, or if keeping the whole process structured and routine without any change in expected reaction works best for you and your child

Try having your child stand between your knees and provide a deep pressure squeeze

Try providing firm yet gentle pressure to the top of their head with one hand while you brush with the other hand

Use a firm stroke or pressure as you comb or wash their hair

Count out loud as you comb, wash, rinse or cut their hair – you can work in sets of a count to 10 (count down or count up) – then give a break before continuing; if your child can, let them make the count

Let them know exactly what will happen, one step at a time; Let them know the time limits for the task

Practice each step over-and-over as tolerated

For cutting - practice without the scissors, lifting up sections of their hair and tugging very slightly to mimic the feel of cutting

Use the word trim instead of cut to make it seem less frightening

Stop by a hair salon for a visit to watch someone else get their hair cut – like you!

Let them see and hear the sounds of the hair salon – snips, buzz of razor, running water, blow dryer, and so on – from across the room

At home, you can let them hold a vibrating toothbrush, your hair dryer, a buzz/razor to get used to the feel and sound

Use a soft towel and clip rather than using a plastic cape; a clip in the back may not irritate as much as the Velcro rough edges on the cape neck closures

Have an extra shirt handy so your child can change immediately afterward if stray hairs have gotten into their shirt / shirt collar

Go to a child’s hair salon that’s more kid friendly – there may be other kids there for your child to watch as well!

Play some favorite music or sing a song during the haircut or hair brushing

If allowed, have your child sit on your lap or in a low chair rather than the higher salon chair

Massage your child’s scalp and neck before the hair trim

Use a weighted lap pad for calming

Consider letting your child hold /play with a toy, fidget, or other item to help distract and calm

Toileting:

For a child to be considered “toilet trained,” it means that the child can get on and get off the toilet, manage their clothes before and after using the toilet, wipe themselves, flush the toilet, and wash their hands. When all of these happen without help or supervision, then you can officially say your child is “toilet trained!”

Toilet training is an ultimate goal, but in reality may take years of trial and error, practice, practice, practice, and more practice. For children with sensory processing disorders, the whole process can take even longer, and be filled with stress, anxiety, fear, and lots of frustration.

As a very general rule, most children do not develop control over their bowel and bladder until they are nursery school age. Most children begin to show signs they are ready to begin toilet training when they are between 18 and 24 months old, though some may not be ready until later than that. By the time they are 3 years of age, your child may be able to use the toilet during the day with few accidents, but still need help with wiping and managing their clothes.

Make your toilet kid-friendly by using toilet seat inserts, foot supports, lighting that is less glaring and bright

To associate the toilet with the need to change and/or sensation of having to go to the bathroom, keep all items (pull-ups, wipes, powder, etc) in the bathroom so they get used to going in there.

For any pull-up, clothing changes related to “accidents” complete in the bathroom – room may be tight, but the idea is to get your child used to going into the bathroom for any toileting related activities and clean-ups

Move needed items down to your child’s level (soap, towels, wipes, toilet paper), using a step stool if needed

Depending on your child’s sensory needs, use unscented soaps, soft towels, check temperature of water, dim the lighting, muffle toilet sounds with towels or padding, keep the ceiling fan off if it bothers them

Make a visual card or booklet to show the bathroom, toilet, toilet paper, sink for washing hands, towels, and talk about the sequence of what will happen in the bathroom

Having a more complex visual card of photo’s or drawings showing pants down, sitting on toilet, wiping, flushing, washing hands may help with understanding the bathroom process as a whole

If the “flush” is a big sensory trigger for your child, leave that picture off of the visual cards so they will not be worrying about that before they even begin the process of sitting on the toilet

If they cannot handle the sound of the “flush” don’t force it – praise their efforts at sitting on and going in the toilet

Work on developing a toileting tracking chart to determine typical times that your child wets / has accidents throughout the week in order to determine their own toileting pattern

Provide a toy to play with, sing a song with them, blow bubbles, and so on while they are sitting on the toilet to help distract and keep any anxiety levels down

Try using moistened toilet tissue or wet wipes

If wet wipes are too “cold” an experience, they do make wipe warmers

Build confidence and reduce anxiety about using the toilet by following a sequence:

o   Have your child start by sitting on the toilet with the lid closed with their clothes on – let them play with a favorite toy or hold items for you while you are “doing your thing” at the sink

o   Have them sit on the toilet sit (with the lid up) with their clothes on

o   Move on when they are ready to sit on the toilet without their clothes on, possibly after wash-up, or while changing their clothes

o   While they are sitting on the toilet ask them to go “pee” (or use the word you usually do) while they are sitting there. If they can sit for 3-5 minutes it may help relax them enough to allow even a small tinkle – praise any effort and success

o   Work toward developing a toileting schedule – before meals, after meals, before bedtime, on awakening – have them sit on the toilet during those times for no more than 5 minutes at a time

If your child seems to only have a BM while wearing a diaper or pull-up you can try to determine what times they usually go, have them sit on the toilet with their pull-up on during those times

o   Before having them sit on the toilet with their pull-up on, tear out the back of the pull-up so that when they go (if they are fairly regular to following a certain time they go) they will “poop” into the toilet

o   Slowly increase the hole in the back of the pull-up so that finally they are just sitting holding a clean pull-up – this “backward chaining” idea can help with the transition to only using the pull-up for BM’s to using the toilet

Encourage your child to jiggle the handle of the toilet and talk about that’s how you get the toilet to work

Take off the tank lid to show them what’s inside the toilet tank and tell them that when you jiggle and push the handle down the water runs from the tank into the toilet and out of the house – if they can tolerate it, let them push the handle enough to feel the pressure and to see the reaction inside the tank – if they will, let them push enough to activate a full flush

Put some food coloring (blue or green) into the tank with your child watching and let them, or have them help you flush the toilet to watch how the colored water comes out of the tank, into the toilet, and then down the drain

Encourage your child to flush after using the toilet

To reduce flush noise, you can close the lid, add some towels on top of closed lid, or you can sit on the closed toilet while your child flushes

If they are not able to stay in the bathroom to flush, let them stand in the doorway and wait until the flush is done – give warning that you are going to flush in the event they are not able to tolerate the noise from flushing

If you are able, let them see you sit on the toilet, flush, and wash hands – make it all a normal routine to see and understand

Let your child help choose a themed toilet seat cover that they like and let them help you put the lid and/or tank cover on

Let your child help decorate the toilet and/or wall next to the toilet with vinyl easily removable stickers

Hang a vinyl coated toilet “go” chart in the bathroom and let your child add their special sticker or star to the chart when they use the toilet

Let everyone know what your routine is so that they all help to follow what you are working on, and how you are presenting everything to your child

Try to take your child to the toilet at regular set times – whether they actually go or not – keep at it!

Let and encourage your child to help pull down and pull up their pants or pull-ups – make them part of the whole process

With dirty pull-ups, have your child help in the disposal – you can wrap up so they will not have to “get their hands dirty,” but let them toss the wrapped up pull-up in the garbage pail (or wherever you are putting them)

Help your child to put a new roll of toilet paper on the holder, hang new clean hand towels, check the soap level, wipe off the vanity after use, bring in a supply of pull-ups, etc.  – get them involved in the process even if they are not up to sitting on the toilet yet – you are getting them used to the bathroom, the materials they will be using and helping them participate in routine chores

Keep certain toys and/or books to use and keep in the bathroom – associate their use with sitting on the toilet and using the bathroom; it takes some trial and error to find the toy or book that works the best for reducing anxiety and encouraging sitting time

Try to keep the sequence, timing, directions, words used, the same each time to avoid confusion, misunderstanding, or sparking a reaction to the situation

Discover if your child responds to praise for efforts and success, or if keeping the whole process structured and routine without any change in expected reaction works best for you and your child

Moving from using the toilet at home to using a toilet somewhere else is a big step – go slowly, use the same or similar methods you have been using at home, try to start with less crowded and less noisy bathrooms, and carry a change of clothing and extra pull-ups for when “accidents” happen.

Take a similar or the same toilet insert seat with you when you are out and about (maybe use a large bag to carry in – you already have a bunch of stuff to take, but having a seat they are used to will help tremendously when they are out in new and unfamiliar bathrooms)

“Holding” their poop, or acting like they are in pain when going may be constipation or another situation – consult with your pediatrician for any issues that need to be addressed; pain and/or difficulty with the act of having a BM will make wanting to try going in the toilet even more difficult

Toileting takes a long time to accomplish. Stick with it. Breathe! Praise efforts and treat accidents very matter-of-factly. If may be frustrating for you, however anger and punishments for accidents or disruptive toileting related behaviors will not make the situation any easier and can actually cause your child to regress or demonstrate even more behavioral issues.

Hand Washing:

While hand washing is great to do before eating, after eating a messy meal, or after some fun messy play, it is an important “last step” in the toileting process.

Whether at home, at school, at a friend’s, or when out to eat, it is important for your child to be able to feel at ease and comfortable with hand washing and drying.

The ability to perform these routine daily tasks are often taken for granted, and expected as a “normal” part of growing up. All these skills require the development, growth and learning involving very precise and complex neurological processes.

It is important that you provide the means for your child to reach the sink where they feel secure in the process.

Using a step-stool, or other sturdy step-up will let your child reach the faucet, be able to see into the sink, and allow them to help support their upper body on the vanity or sink edge in a safe manner.

Make your sink area kid-friendly by using a sturdy foot stool in order to reach the sink and water easily

Move needed items down to your child’s level (soap, towels, wipes)

Depending on your child’s sensory needs, use unscented soaps, soft towels, check temperature of water is “good to go”

Demonstrate and teach each step – let them see you turn the water on, wet hands, apply soap, wash, rinse, and then dry your hands – show and talk them through each step

If one type of soap does not work, or if your child does not like a particular type of soap, try a different one – soap comes in foam, gel, a bar, liquid, scented, unscented, small personal size bars, textured bars of soap

Colored and color-changing soaps (foamy, gels, pens) may turn the whole thing into a “fun” time for your child

Help them as needed, letting them do as much as they can by themselves to help learn the process and details

Using child-safe water-soluble markers or paints, make “dots” or “lines” on your child’s hands, and then have them wash them away – start with only one mark to see how your child is going to react!

Have different types of “drying” items available – your child may do fine with a paper towel instead of a hand towel, or may want to even “shake their hands dry.” Go with their learning and tolerance levels!

In public restrooms with hand dryers – you may want to carry a small wash cloth or soft disposable towels to avoid use of the hand dryer if this causes your child distress

It may be impossible to completely avoid areas where hand dryers are in use, but giving your child the choice to use one or not is important

Try singing a short song or telling a little story (only about 15 to 30 seconds long at most) to help your child understand how long you would like them to be washing their hands

Give lots of praise for their efforts – even if it is only standing on a foot stool to look into the sink, or turning on/off the faucet – award all accomplishments with praise!

Give lots and lots of opportunities throughout the day!

Eating and Self Feeding:

Many children with sensory sensitivities have issues related to eating and drinking. Difficulties can be related to chewing, present as behavioral issues and outbursts, choosing a restricted or very limited diet, or mouthing on food and non-food items.

Before beginning making any changes to the current situation with meals and eating, start making a record for a week or two by making a Food and Behavior Diary

Introducing some of the following activities prior to mealtimes or snack times may help your child accept new foods or experiences.

Activities that stimulate the mouth include:

Heavy pressure across the roof of mouth may be calming or alerting depending on your child

Using chew kid-safe items for biting, providing deep pressure, grinding of teeth

Use a pediatric toothbrush or gum cleaners for brushing to teeth, gums, roof of mouth

Use of a vibrating toothbrush as tolerated

Try a variety of food textures, colors, flavors – present “just one bite” to choose from at every meal to increase exposure and opportunity to try new foods

Start with adding in a food that is similar to a food that they already will tolerate such as texture, chew-ability, blandness or spiciness, shape, or color, etc. For example, if your child only eats chicken nuggets from a specific eatery, try to add in nuggets that are a different brand or from a different location;

Try serving different condiments in separate bowls to see and hopefully try over time

Serve the same type of food but a different brand (for small change of taste or look)

Offer the new food on a daily basis – I am not suggesting putting the food on the plate or bowl and expecting them to eat it, but rather put it on the table near where they eat so that they can see it, smell it, get used to seeing it. Making gradual changes can bring acceptance.

Moving the new food closer to the plate as tolerated with the plan to actually put a piece, or bite of the new food onto their plate.

Try not to make a fuss about them having something new on their plate, but let them get used to having this new item now in their space; if they flick it off, throw it, or display behaviors, try again the next meal.

If they respond and understand, you may want to let them know that they do not have to eat the new item, but to just let it stay on their plate until it is time to clean up

Continue to repeat offering the new same food item once or twice a day without expecting them to eat it. If others at the table are seen enjoying it, that may encourage your child to touch, smell, or taste the food – at their terms and with them in control.

Ask for help in putting food on YOUR plate, asking for help with foods they will eat and foods they will typically refuse to try

Ask for help in scooping, stirring, mixing, opening a jar or package of food that they will eat as well as those “new” foods they will not yet try

Develop a Sensory Diet

Discuss and plan this with your child’s services providers as the best choice is in-person evaluation and assessment in order to meet your child’s needs.

Sensory diets are a common strategy used when addressing a child’s sensory needs in relation to their specific needs. Sensory diets are based on a child’s specific sensory needs – Working with your child’s OT/PT/ST/service providers experienced in therapeutic sensory diet planning and development is strongly recommended.  

By providing a therapeutic sensory diet, you may, over time, restructure and retrain a child’s brain to process sensory information from their sensory receptors in such a way that will promote self-regulation of activity, focus, mood/behavior, and the ability to process the sensory information to participate more fully in regular home, social, and school routines.

02/13/2021

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