Week 7

Activities of Daily Living: children

Encompasses taking care of one’s body

Children develop with increasing levels of competence, mastery and self reliance to meet their own needs

Development of Activities of Daily Living

Age	Milestones
0-3m	•Child is able to latch on while nursing or bottle feeding, •Is able to calm during car rides when not tired or hungry, •Enjoys bath time, •Is usually able to tolerate diaper changing without crying
3-6m	•Shows interest in food; Opens mouth as spoon approaches, Moves pureed food from front of mouth to back; Begins to eat cereals and pureed
7-9m	•Is able to transition from milk or formula to infant cereal; In a high chair, holds and drinks from a bottle; Starts to look and reach for objects, such as food that is nearby
10-12m	•Is able to self calm in car rides when not tired or hungry; •Is not fearful of tipping head back when moving from sitting to lying on back;  Is eating an increasing variety of food •Can usually participate in dressing without becoming upset;   •Has an established sleep schedule; •Is usually able to calm self to fall asleep
13-18m	•Holds and drinks from a cup
2-3 years	•Is aware of sensations such as a wet diaper or underpants; •is able to take appropriate bites of food, does not always stuff mouth; •Is able to tolerate and stay calm during haircuts
4-5 years	•Is able to use utensils to pick up pieces of food •Is able to tolerate and wear textures of new and varied articles of clothes • Is able to take appropriate bites of food, does not always stuff mouth • Is able to tolerate haircuts and nail cutting without crying • Is able to adapt to changes in routine;   •Can take bath or shower, although preference may be present;   •Eats a diet rich in various foods, temperatures, and textures; •Can drink from a cup and straw without dripping; •Is able to complete everyday tasks that have multiple steps, such as dressing; • Frequently wakes up rested and ready for a new day

ADL Performance steps

•Obtain the supplies

•Use of the supplies

•Complete the steps of the task

ADL Performance Example Bathing

•Obtain: Obtain the supplies for bath

•Use: Use of the supplies during bathing

•Complete: Complete the steps of the task

Factors Affecting ADL Performance

•Child Factors & Performance Skills

•Performance Environments & Contexts

•Social Environment

•Cultural Environment

•Physical Environment

•Activity Demands

Cultural Factors Affecting ADL Performance

•Shift from Cultural Competency to Cultural Humility (Agner, 2020)

•Cultural Humility is defined as a way or incorporating multiculturalism through flexibility and awareness of bias.

•Impacts the type and availability of tools, equipment, and materials for ADL performance

•OT Role: Increase awareness of bias from experiences with reflective practice

•Important implication for Early Intervention

•Values (ex. Dependency vs Interdependency)

•Goals

Evaluation of Activities of Daily Living: interview

•Parent goal

•Identify person and environment factors influencing performance

•Identify environment, context, steps of test and child capabilities

•Compare the demands of the task with child’s actual performance skills

Evaluation of Activities of Daily Living: observation

•Naturalistic/Ecological

•Task Analysis

•Environmental

•Level of Assistance Needed

•# of all the modifications

Evaluation of Activities of Daily Living: standardized assessments

•AMPS

•PEDI

•REAL

•Wee FIM

•SFA 

•COSA
COPM

•GAS (Goal Attainment scale

•PACS (pre-school activity card sort

Approaches to Facilitate Activities of Daily Living

•Promoting or Creating

•Establishing, Restoring, and Maintaining Performance

•Modifying or Adapting the task with Assistive Technology

•Preventing Problems and Educating Others

•(Behavioral)

Approaches: Promoting & Creating

•Aims to offer all children the opportunity to engage in ADLs

•Targets the General population vs Individual Direct Intervention

•Occupation Based Models

•MOHO

•PEOP

•Developmental

•Team and System Approach

•Tier 1 approach

•Universal Design to promote Usability

•Visuals & Routine

•Inservice to Teachers

•Campaigns

•Consultant

Approaches: Establishing, Restoring & Maintaining Performance

Consider typical developmental sequence

Based on the child’s body structure and function

Select age- appropriate tasks and roles for intervention

Approaches: Prevention & Education

•CO-OP - cognitive orientation to occupational performance

•Coaching & Metacognition

•Anticipatory problem solving - anticipating problems/issues and generating solutions ahead of time.

•What is the task to be completed

•What are the objects needed to complete the was?

•Are the objects available, if not what else can be used?

•What are the safety risks and hazards within the environment?

Behavioral Approach– Cueing

visual cue

Behavioral Approach - Prompting

donning shoes example

Verbal: “Keep Pushing Until the Shoe covers the heel”

Gesture: “Point at the Heel”

Visual: Refer to graphic task “See how the shoe covers the heel”

Student Modeling – Ask parent or sibling to model

Adult Modeling – OT demo

Physical Assistance -> Follow Hierarchy of Physical cues

Behavioral Approach - Chaining

Chaining Steps of task

Start from Top or Bottom

Points to consider

Establish Baseline

Determine the task you will be doing, identify which type of chaining will you use

Decide which step you are going to be working on teaching

For the other steps you are often providing physical assistance

Behavioral- Forward Chaining

Child performs the first step, then the second, and continues to learn all steps in a sequential order with cueing/prompting as needed until he or she performs all steps of the task.

Forward chaining has the advantage of using behavior momentum, as the 1st step is often the simplest, easiest step.

Helpful for Children who have difficulty with sequencing & generalizing activities.

Behavioral- Backward Chaining

•OT performs most of the task

•Child performs the last step of the task

Helpful for children with low frustration tolerance or poor self esteem as it gives immediate success

Task completion usually paired with a reinforcer

Once the last step is mastered at an independent level, then move to the last 2 steps, then the last 3 steps, etc.

Forward and Backward Chaining Examples

Occupation	Forward	Backward
Dressing	Child pulls shirt over head independently but needs help putting arms and sleeves through the shirt	OT assists child with donning shirt over head and arms, child pulls shirt down over belly
Feeding	Child can grab spoon from plate but needs assistance to scoop food and bring to mouth	OT assists child with grabbing and scooping food but the child can bring it to the mouth.

examples of Intervention Strategies: Dressing

•Establish baseline

•Choose appropriate clothing to begin

• Choose more simple clothing:

  • Elastic Vs Fasteners

  • Loose vs Tight

Choose the right time and context

•Provide visual supports:

• Visual/Environmental Cues

• Access to a mirror for visual feedback

Positioning

•Prep activities/strategies

•Adaptations 

•Determine appropriate rewards (behavioral strategies )

•Teach specific skills based on task analysis 

•Use prompting, video modeling and chaining to teach the steps

•General dressing strategies

•Poor balance - use side lying

•Able to sit but is unstable  - corner seat, sitting on chair w/ arms

•Dress affected side first

Case Example- Spastic Quadriplegic Cerebral Palsy

•Bend hip and knees before putting on shoes and socks

•Bring shoulder forward before putting arm through sleeve.

Intervention Strategies: Dressing for weather

Application to Help sequence and chose clothing based on weather

Intended Use: Motor Planning and EF difficulties specifically initiation and organization

FOR: Cognitive Approach

Intervention Strategies: Bathing

Adapting the task/environment

Safety rails, grab bars, lighting

Hypersensitivity

Visuals to help Sequence

Caregiver Positioning/Handling

Prep activities to restore Function

Endurance

Gradation of Force

ROM

Balance

Intervention Strategies: Feeding

Interventions for Sensory Processing Disorders

Oral Hypersensitivity

Poor oral sensory Awareness

Behavioral Management interventions

Positive reinforcement

Environmental Adaptations

•Sensory stimulation

•Scheduling and location of meals & length

Positioning Adaptations

•Seating

•Splinting: Mckee, Benik, Immobilizer

•Adaptive equipment/AT: SAEBO Mobile Arm Support

Intervention strategies: Toilet hygiene & bowel and bladder management 

Bladder problems depend on type of neurological condition and lesion

Identify the best bladder management program for a child w/ collaboration w/ nurse, physicians or ABA

OT Important considerations

How does the child handle clothing before, during and after toileting?

Family expectations before, during and after toileting,

Adapting the task and environment

Postural Control

Visual Attention

Tactile Awareness

Interoception

• Connect External body clues to internal senses

Social Stories

Visual Schedules

Positive Reinforcement

Timers

Menstrual Hygiene

• Tactile awareness

• long handled mirror

Intervention Strategies: Personal hygiene and grooming

Hypersensitive to brushing teeth

Massage the area

Flavored Toothpastes

Social stories to prepare

Adapt the task (modify the toothbrush)

MC/ML – directionality/transfer

Biomechanical/Developmental – FM Skills

Hygiene and grooming different intervention

•Hairstyling and Cosmetic use

•Facial Cleansing

•Applying deodorant

•Identify needs, respect cultural values

•Interventions

• •Adaptations of a task

• •Visuals

• •Restore

  

ADL: Prep Activities

Postural Control

Wrist stability

Bilateral hand use for manipulating

Visual Attention/Precision

Put in tasks, opening backpack

Sequencing

-working on postural control - getting arms away from body, b/l BUE co-contraction.

Backwards coat technique

Intervention Strategies: Hair Cuts

Intervention Strategies: Sexuality

Understanding of Impact of Body Structures/Functions of Specific Conditions and the effect on sexuality

Intact sensation, mobility, puberty, bowl and bladder

Ex. CP, Spina Bifida, SCI

Make the right Referrals

Psychologist, Gynecologist, Physician, Social Work

Understanding of Typical Sexuality Concepts Discussed with Children and Adolescents

Appropriate touching, personal space,

Intervention:

CO-OP to help promote self determination and self awareness

Social stories, visuals, role playing, observation of videos

Intervention Strategies: Sleep and Rest

Evaluation:

Regular sleep pattern, where the child sleeps, typical routine, bedtime schedule, duration

Intervention - team approach

Bedtime routines and habits

Physical aspect of the environment

Refer to Sleep Study

Letters of Medical Necessity For sleep

Durable medical equipment

Components of LOMN:

General Narrative of Client Condition

Current Sleeping situation

Alternatives that were considered

Risk Factors for injury

Denote Specific Requirements of Product to address needs

Safety Rails, height

“The imperative that the specific medical needs and complex care be addressed”

IADLS

• Home Management

• Shopping & money Management

• Meal preparation

• Community mobility

• Health maintenance

• Care of pets

• Care of others

• Safety procedures

• Emergency Response

Complex Occupations

Children Engage upon Developing Autonomy in ADLs

Promote self determination & self sufficiency, health and social participation

IADLs: Typical Development: preschool

•Home

•Clean up

•Prepare cold snack

•Make Bed

•Outside

•Library visit

•Community Events

•Playground

•Middle Childhood

•Home

•Prepare Simple Meals

•Take care of Space & needs

•Put away Groceries

•Outside

•Asist with grocery shopping

•Participate in after school programs, community center activities

•Younger  Adolescence

•Home

•Plan and prepare Simple hot & cold meals

•Use of communication devices

•Babysit

•Manage Medications

•Outside

•Use public Transportation Independently

•Volunteer

•Emerging Safety Awareness

•Older Adolescents

•Home

•Operate kitchen appliances

•Home repairs

•Outside

•Driving

•Works Part time

•Volunteer

Factors Affecting IADL Performance

•Child Factors & Performance Skills

• Interest, Motivation, Preference

•Performance Environments & Contexts

•Social Environment

•Cultural Environment

• Family Expectations

•Physical Environment

•Activity Demands

Evaluation of IADLs

•ASK (Activity Scale for Kids)

•age 5-15

•performance and capacity of a child - personal care, dressing, eating, etc

•CHORS

•Age 6-14

•child’s participation in household tasks

•PEM-CY

•age 5-17

•participation in home, school, and community

Theoretical Models to Facilitate Instrumental Activities of Daily Living

•MOHO

•Self Determination

•Cognitive

•CO-OP

•Ecological

•Adaptation & Environmental

•Behavioral

•Reinforcement, Prompting, Video Modeling

IADL Approaches

Sensory Integration: Heavy Work Activities within IADLs

Driving & Community Mobility

Address Underlying Proximal Factors

Driver Evaluation & Rehabilitation

Virtual Reality

Assistive Technology

Transition Programs