Supporting and Teaching Daily Living Skills
Getting Dressed. Brushing Teeth. Potty Training. Washing Hands.
These all seem so simple to most adults but when we actually break down the steps involved, these are hard!
For example with washing hands:
Step 1- turn on water
Step 2- wet hands
Step 3 - get soap
Step 4 - rub hands
Step 5 - rinse soap
Step 6 - turn off water
Step 7 - dry hands
And these are the steps if the child has the motor skills and prerequisite skills needed to do this!
If they aren’t tall enough and we need to add a stool, that’s an additional step.
AND that is if all the adults are prompting the same order - if we get soap and then turn on water, it only complicates the issue for the learner.
We are teaching this 7+ step skill to 3+ year olds, and with ASD, they may not have the natural tendency to pick up on model prompts or be able to follow verbal instructions, especially if they are not age appropriate and the adult is using too many words.
This is a recipe for stress for parents and children. There are some strategies that can be used by parents of neurotypical and neurodivergent children which is great where there are siblings in the picture. Try some or all of these strategies and see what works for you.
When Initially Teaching the Daily Living Skill:
Create a consistent sequence for the skill
Break the larger skill down into each individual step
Like the steps for handwashing above
For toileting: Step 1- walk to toilet, Step 2- pull down pants (pull up skirt/dress, etc.), Step 3 - pull down underwear, Step 4- sit on toilet, Step 5 - wipe, Step 6 - pull up underwear, Step 7 - pull up pants, Step 8 - flush
You can search for “task analysis brushing teeth” or another skill on a search engine for ideas - ensure you modify them for your child and the environment or items they will be using
Write down the order and keep it somewhere for reference
Ensure that all adults working on this skill with the child are working on the same steps in the same order every time.
This includes parents, caregivers, older siblings, BTs/ABA team (when appropriate), grandparents, etc. Write a list or have a visual schedule for the child to follow as well.
The steps Dad takes are likely different than the steps Mom takes to put on a shirt even though it is the same action - head first, one arm first, scrunch the bottom to the top, etc. If Dad is prompting one set of steps and Mom is prompting another, this will lead to frustration for all involved.
Whenever possible, the order of steps should be based on what is easiest or most beneficial for the child.
If the child is showing a natural tendency to not wet the toothbrush before or after putting the toothpaste on, check with the Dentist to see if that step is really necessary or if it is ok to skip for now. It is ok to target the most important steps first and then work on the ‘nice to have’ steps later.
If the child seems to be left handed, then the left hand is likely the better hand to use to turn on the faucet, grab the soap, etc. This may mean the adult will be prompting the child’s dominant hand with their nondominant hand with Hand Over Hand prompting, which may feel awkward or backwards for the adult
After a few times running through the steps, you may need to modify
You may find that the steps don’t make sense, need to be broken down into smaller steps, or the child shows independence or preference with another approach.
It is ok to alter the steps if there is a specific reason like those above or others. It is better if these changes are made sooner rather than later to limit the number of times the child is prompted in the old way
Think about if sitting on the floor or a chair is better for the child to put on shoes, pants, etc. Or if going Sock 1, Sock 2, Shoe 1, Shoe 2 or Sock 1, Shoe 1, Sock 2, Shoe 2 makes more sense after a few days
Think About the Prompt Your Child Requires for Each Step
Once you have the list of steps, determine what level of prompting your child requires for each step. This may be different for different steps
Limit vocal prompts for Daily Living Skills
It is harder to fade out vocal prompts compared to physical prompts like a gesture or model prompt
It is generally recommended that you use a Physical Prompting Hierarchy for this but it is not always the case. Contact a professional if you have questions on Daily Living Skills.
Following a Physical Prompting Hierarchy, from most to least intrusive, the prompts are
Hand over Hand/Full Physical
The child's hands complete the step with the adults hands
This may mean the child's hands inside the adults hands or the child's hands holding on to the adults hands
The adult should never force the child to complete the steps. If the child is resisting, there may be another reason the child does not want to do it. Follow your child’s behavior if they are unable to communicate - it may be uncomfortable, hurting, or otherwise annoying. It may take time to desensitize the child to the skill. In this case, a professional should be contacted for more support to ensure the child is able to work through it in a trauma-informed way following the child's assent.
Partial Physical
If the child basically understands what to do with their fingers/palms, then you can fade to the partial physical prompt for the step
This may include supporting under the child's forearms to guide their hands to the appropriate location. This may also be gently pushing the child's elbow to extend the arm. The specific partial prompt will depend on the step being targeted.
Again, the adult should not be forcing the child to complete the steps. In this case, a professional should be contacted for more support to ensure the child is able to work through it in a trauma-informed way following the child’s assent.
Touch
This can be a good prompt when the child is getting pretty independent with the step
A light touch on the hand or arm indicating to do the next step with that body part
Model or Gesture
This can also be a good prompt when the child is getting pretty independent with the step
A model prompt would be the adult doing the action then the child imitates. Being able to imitate the step is a prerequisite to using this strategy. For example, the adult rubs their hands together to indicate the next step in hand washing. The child sees the adult and then imitates by rubbing their own hands
A gesture prompt might be to suggest the next step with a point or other gesture, like pointing to the soap.
Visuals
Visuals can be a great strategy across settings when learning these multi-step skills
Using cartoons, pictures, or words (based on what the child can access independently), can be beneficial and do not need to be faded
The benefit of step-by-step visuals of hand washing routine, toileting routine, brushing teeth routine, etc. is that the child can always reference them, even after they are independent with the task
The same visual should be used across locations - for example if the child uses two bathrooms, the same visual should be in front of both sinks
You can search for ideas of visuals to use
You can search for “step by step visual brushing teeth” or another skill on a search engine for ideas - ensure you modify them for your child and the environment or items they will be using
The visual can be used throughout all the prompting levels above. The adult can point to the specific step on the visual before providing the prompt
Many preschools, pre-ks, and lower grade levels will have hand washing and/or toileting step visuals in the bathrooms. If they do, see if you can use the same or a similar one
Each time you work on it, use the least intrusive prompt to ensure success
When first teaching, this will likely be a HOH/Full Physical or Partial Physical prompt but the child could be completely independent with some
Over time, each prompt level will fade once the child knows the expectation and can complete it successfully with that prompt level.
Each step should be compared to itself so some steps may be independent and some may require HOH prompts - that's ok!
After a few days with each specific prompt level, try the next less intrusive step
For example, if the child has done it for a few days (3-5ish, depending on the child) with a partial physical prompt without resistance, try a touch, gesture or model prompt.
If the child is successful with the touch, gesture, or model prompt, great! Keep targeting that level from now one
If the child is unsuccessful with the touch, gesture, or model prompt, no problem! Keep up with the partial physical prompt for a few more days
Keep track of the prompt level used, especially if more than one person is targeting it
Watching the prompt levels fade from HOH to Partial physical to gesture prompts to Independent over time will also be reinforcing for you to see!
Since these skills are complex, it is easy to get overwhelmed or annoyed that it takes a while. Know that while the skill may not be mastered, progress is happening.
Prompt from Behind Whenever Possible. If Not, the Side
For washing hands and brushing teeth, these are typically pretty easy to prompt from behind. Some clothing items may be easier from the side and that is ok too. We want to limit being directly in front of the child
Again, this may take some adjustments from the adults prompting. It might not be super comfortable or easy to prompt from the back but it will be easier to fade prompts and increase independence
It is Easier to Provide and Fade Prompts
When your hands are coming from behind the child and over their hands while washing or brushing teeth, you are better able to HOH prompt each step since it is the same direction you are facing
When fading physical prompts, we will typically work up the arm to fade the prompt to independence. Standing behind will ensure you are close enough to the child to provide those prompts but can also easily change the prompt level as needed (see below for ideas on how to
Limits Accidentally Reinforcing Scrolling Behavior
When learning tasks like these, the child may scroll through responses if they are unsure of the next step
We have a natural tendency to start to smile or our tone will get higher as the child reaches for the correct step
The child may attempt a few different things to see if the adult starts to give the reaction - for example, the child might try to pull up their pants after one leg, take them off, etc. if they are unsure to put their other leg in next.
We should limit the mistakes the child is making in between steps so if the child is scrolling, they may not be ready to fade the previously used prompt. If this is happening, go back to the last successful prompt
After The Skill is Pretty Consistent- Doesn’t have to be perfect or completely independent!:
Provide Appropriate Choices:
Choices can be simple or complex depending on the age, independence, and behaviors related to the skill
“Do you want to do it on your own or do you want help?”
“Do you want mom or dad to go with you?”
letting the child pick between two different shirts, two different pairs of pants. This can be a helpful part of any part of the childs routine.
Picking between a blue toothbrush and a green toothbrush
Getting dressed or brushing teeth first? Getting dressed before or after breakfast?
Provide two age-appropriate, easily understood options. If the child independently provides a third option that is acceptable, that is ok! It’s great that they are communicating what they want
This is especially important for older children or children that are more resistant to cooperating with or completing these tasks.
By having some control over the situation, they may be more likely to complete the task. They may also have preferences but are unable to communicate it independently so by offering them two choices, they can pick the one they prefer without needing to find the language to specify
Some support may still be required, even after it is mastered
Daily living skills may require prompting if the child is sick, with a new clothing item, in a new bathroom, etc.
If the skill was previously mastered and the child is not completing the task independently, use the least intrusive prompt to ensure success.
This may be a touch, gesture, model or other prompt.
If the child is small and young enough, it is ok to do these things for them if they are not up to it. If they are older, try providing some choices, help, or reinforcement to complete the necessary things while sick or tired. Pick your battles.
As with any child, there may be setbacks or delays with this process. It is important to remember that you are the adult that knows how to do it and the child is learning to do it. It is normal to get frustrated while working on these but ensure that you look for instances of progress as well. If you know you are not up to helping or following through, then don’t place the demand or you can modify the demand for that day. Try to use things that are fun for the child -like music or songs while doing the tasks, using a special soap or stool in the bathroom, etc. Due to the overall importance and frequency of these tasks, it will be much better to go slowly and ensure the child is supported, rather than making it a frustrating experience for anyone.