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Caregiver-directed therapy to promote independence in self care: working in the setting where self care naturally occurs allows the therapist to gain an understanding of the all the factors influencing the situation. Then the therapist's recommendations can directly address the specific challenges, and the recommendations can be fully implemented.

Caregivers of children with special needs can direct an at-home occupational therapy program to promote independence in self-care tasks.

By the age of eight, most children in western cultures are independent in self-care tasks (eating, toileting, dressing, and grooming). This independence allows children to fit in with peers. When working toward independence, children develop a variety of skills including physical abilities, problem solving, attention, and patience. In contrast, children with special needs might experience delays in gaining independence. Needing and receiving help over time may cause difficulties. For the child, not being independent in self care may contribute to feelings of inadequacy, shame, and, in the extreme, learned helplessness. Learned helplessness occurs when an individual senses that his/her actions will not result in desired outcomes and therefore stops putting forth effort. For caregivers, providing the extra help with self care can be a source of time constraint, increased emotional stress, and physical burden.

Learning self-care skills depends on practice. Occupational therapists often make the recommendation to have the child practice self-care tasks regularly at home or they may provide home exercise programs to address the needed skills. However, either of these can often be challenging for caregivers. Caregivers may have difficulty finding time within their family routines. Caregivers might not be able to analyze and problem solve the specific problem(s) that the child is having.

In-home occupational therapy services might be better suited to address self care. Working in the setting where self care naturally occurs allows the therapist to gain an understanding of the all the factors influencing the situation. Then the therapist's recommendations can directly address the specific challenges, and the recommendations can be fully implemented. However, in-home therapy services can be difficult to obtain through the usual service providers (schools and outpatient rehabilitation centers) because of limitations in areas of service (school-based therapy must be educationally relevant), reimbursement through insurance, or productivity demands on therapists. Alternatively, caregivers may wish to pursue in-home therapy services privately. Considering the cost, preparation will reduce the number of visits needed and ensure that the family's needs are met.


The most critical factor to be considered is the therapist's willingness to take direction from the caregivers. The therapist should demonstrate creative problem solving. Asking the therapist to describe some past challenging situations and the solutions may allow the caregivers to judge the therapist's communication skills, knowledge, and experience. Last but not least, the therapist's personality is important to consider. He/she should be comfortable in the family's home. He/she should interact with the caregivers as colleagues, not as clients. He/she should be warm and engaging with the child.

The therapist should carry the state's professional credentials (licensure or certification) and professional liability insurance--caregivers may request documentation. Finally, the caregivers and therapist should mutually agree on the terms of payment for service. To negotiate these, caregivers can gather information about hourly rates from their medical insurance providers and local service providers.


One approach for choosing the tasks to focus on may be to prioritize those that are the most problematic. For example, caregivers can note which tasks take the longest, which task the child needs most help with, and which create the most frustration. However, caregivers must be wary of dismissing tasks that they themselves "don't mind doing." Should the child have, or nearly have, the skills to do these tasks for him/herself, having the caregiver's repeated assistance may contribute to feelings of helplessness. Similarly, caregivers may wish to prioritize those tasks that they judge that child should be able to do given his/her skills, but doesn't do.


One method of communicating the caregivers' priorities to the therapist is based on a clinical assessment commonly used by occupational therapists, the Canadian Occupational Performance Measure. The caregivers select as many as five priority tasks they would like to initially focus on. For each of these, they would rate the child's current performance from one (1) to ten (10), where one indicates "not able to do it at all" and ten indicates "able to do it extremely well," and their satisfaction with the child's current performance, from one "not at all satisfied" to ten "extremely satisfied."


Next the caregivers can arrange to have the therapist present when the relevant tasks are naturally occurring, for example morning or bedtime routines. Having the real constraints of time pressures and the activities of others in the house will allow the therapist to appreciate the details of the situation. For some families, it may require more than one visit to be comfortable enough to go about their usual business with an outsider present. The therapist will watch for details in the child's performance, the environment, and the task itself.

After the initial observations, the caregivers can request that the therapist make a list of the factors that most influence the child's performance. The caregivers may provide insight to the list and/or may modify it, according to their own perceptions. Once the factors are agreed upon, the caregivers and therapist would work together to problem-solve and create strategies to promote the child's independence.


While every child and every family is unique, several strategies are commonly useful in promoting independence in self-care.

Providing Opportunities to Practice

Caregivers can unintentionally become accustomed to providing too much help. Sometimes, this can be because it is easier, faster, and prevents tantrums. Other times, caregivers are uncomfortable seeing their child struggling or frustrated. Individualized strategies can transition children toward independence. For some families, the caregivers need to step back from direct involvement and allow others, perhaps the therapist, to be present while the child works on new skills. In other situations, extra time and privacy might be provided for the child to complete self care. Often, this can be easiest on weekends at first.

Visual Schedules

A visual schedule presents images or icons depicting each step of a multi-step task in sequential order. They can also include words, phrases, or instructions. Visual schedules break a task down into parts for skill learning, sequencing, and cuing attention. Visual schedules can be made for tasks such as getting dressed, brushing teeth, or packing a school bag. They can be laminated to be waterproof to hang in the shower. Each step can be laminated and mounted to a strip with hook and loop fastener to allow removal after completion. Visual schedules can feature photographs of the child him/herself completing each step of the task.

Visual schedules proved a valuable tool for increasing independence in the morning for seven-year-old Grace, who had developmental delay because of a rare genetic condition. Grace seemed to resist getting dressed alone because she enjoyed the time she had with her mother when getting help. Though judged to be capable of dressing herself, she relied on prompts and assistance from her mother. The true effect of receiving help with dressing was keeping her mother nearby. The visual schedule provided the prompts needed to move from one step to the next. Grace learned to get dressed on her own and gained positive attention for her accomplishment


Organizational Strategies

Altering the way materials are organized can often promote independence. For example, laying a child's clothes out with the undergarments on top and outer layers on the bottom can reduce his/her need to sequence the task. Storing undergarments and pajamas in a bathroom drawer can facilitate getting dressed for bed after a shower. Devoting a half bathroom to the child can limit distractions of a busy household.

Assistive Devices

Assistive devices are tools and materials that make tasks easier. These are designed to make up for challenges that a child faces. Assistive devices may be used temporarily or for the long term. They may be commercially available or created by modifying existing devices. The following are some common examples: a pocket on a bath mitt to hold a bar of soap for one-handed washing, elastic shoelaces to eliminate the need to tie and untie shoes, and a piece of rubber shelf liner to keep a toothbrush from slipping while toothpaste is applied.

A homemade assistive device made it possible for Alex, eight years old, to shower independently. Alex had hemiplegia, or weakness in one hand, because of a stroke at birth. He had difficulty using a bar of soap and in applying liquid soap to a washcloth. The solution for this was to add a pocket to a child-friendly bath mitt to hold a bar of soap. He wore the mitt on his weaker hand and used it to scrub his body. This left his stronger hand available for aiming the shower head.

Behavioral Strategies

Behavioral strategies can improve participation and reduce helplessness. Strategies can include increasing the amount of praise for trying, ignoring undesired behaviors, and implementing a reward system. An example reward system would be earning a star for giving "best effort" and trading in sets of stars for a reward.


Being able to care for one's self boosts self esteem and smoothes family routines. Occupational therapists can work directly with families in finding strategies that will enhance success in the home.

By Alexia E. Metz, Ph.D., OTR/L, Jennifer L. Koval, OTD, OTR/L, Anna Wearsch, OTD, OTR/L, Julie R. Pommeranz, MOT, OTR/L

About the Authors:

Alexia E. Metz, Ph.D., OTR/L is an assistant professor in the occupational therapy doctoral program at the University of Toledo. She provided academic mentorship to J. Koval and A. Wearsh. Jennifer L. Koval, OTD, OTR/L and Anna Wearsch, OTD, OTR/L are graduates of the University of Toledo. To fulfill their doctoral requirements, they conducted in-depth case studies that have led to this aricle. Both are now practicing occupational therapists in northwest Ohio. Julie R. Pommeranz, MOT, OTR/L, is an occupational therapist for a private pediatric practice in north-west Ohio. She provided clinical mentorship to J. Koval and A. Wearsch.
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Author:Metz, Alexia E.; Koval, Jennifer L.; Wearsch, Anna; Pommeranz, Julie R.
Publication:The Exceptional Parent
Geographic Code:1USA
Date:Aug 1, 2012
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