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Supporting Increased Independence in Activities of Daily Living for Children with Autism - Text Transcript

- It's my absolute pleasure to have the opportunity to introduce our presenter today.

Victoria Cernjak is an occupational therapist, and she's been working in pediatrics since 2006.

She has a wide variety of experience and she's worked in three provinces, two IEBI programs.

She's worked for three school boards in inpatients, outpatients, including homes and daycares, public sector, private sector, direct care, and leadership roles.

The majority of Victoria's time in pediatrics has been spent supporting young children, mostly children from ages three through eight with a diagnosis of autism and their families.

And Victoria is currently on leave from her direct clinical work as an occupational therapist while she's supporting the IWK kids rehab team as the interim rehab coordinator.

And we're thrilled to have Victoria with us today, and really excited to hear what she has to share.

So I will turn the presentation over to you, Victoria.

- Thank you.

Hi everyone.

As Shelley said, my name is Victoria and I use the pronouns she, her.

And I am really excited to be here today.

You know, sometimes excitement and nervousness feel the same in your body and it can be tricky to figure out which is which, so I think, I'm mostly excited and have done my best to try to cram lots of, hopefully helpful information into a 90 minute periods.

So we will go ahead and get started.

All right, and Shelly, you'll let me know if you can see, I think you should probably be able to see the slides but just wanna make sure.

I also should let you know that sometimes I talk really fast, so I'll do my best not to talk too quickly, but if you do think I'm speaking a bit quickly, please just pop a note into the chat for me to slow down a little bit.

I have a presentation and slides, I'm pretty informal, so at any point, as Shelly said if there's questions just pop them in and we can talk about things as we go.

One other note just before we begin is in the title you'll see that I wrote children with autism spectrum disorder.

And I know there's lots of discussion around using different language, like perhaps autistic child or autistic person, et cetera, and in the clients and families I work with it's really an individual preference and it does still seem to vary, and I know those conversations are ongoing.

So please, whenever that pops up, and I don't think it pops up too much in this chat, but keep in mind that those are interchangeable terms for now.

And one last thing before we get started is to acknowledge that we are located in Mi'kmaw'ki, the unceded and ancestral territory of the Mi'kmaq people.

The land in which we occupy is a shared privilege and it is one of which we benefit greatly based on broken treaties, the legacy of residential schools and colonial policies such as the Indian Act.

Despite these horrific events, indigenous populations continue to exude resiliency and pride amidst backdrop of ongoing colonialism and oppression.

They are not relics of the past, they are worth celebrating.

So my hope for today is that people leave with some ideas, some information that is helpful for them.

And so if you would be so kind to type in either the Q&A or the chat box, what you're really hoping a good piece of information or helpful nugget might be at the end of the day around certain areas.

What would that be?

If you could type that into the chat or Q&A and let me know.

And hopefully some of that will be covered automatically, and if not we'll try to make sure that we touch on it.

All right.

Haven't heard anything, so we'll cross our fingers and hope that what we have here is gonna work out fine for us.

And if anything pops up to you feel free to pop it in.

So Ashley said I am an occupational therapist, and as occupational therapists we really are trying to consider the person, the environment, and the occupation and how all of those things intersect.

So the occupation is anything a person needs or wants to do in the run of a day.

So that sounds quite broad, right?

And it is, for sure.

So when we're looking at participating in activities of daily living as one of the types of occupations, we're really looking at self care, which could be toilet training, dressing, meal times, productivity, which could be things that are happening in school or the routines at school.

It could also be play.

Sometimes for kids, play is work, right?

And then we're also looking at leisure, which is sometimes play, but also other activities that you enjoy in your downtime.

So we look at all of those things.

And we're really looking at the fit between the person's skill, the requirements of the occupation and the challenges or supports in the environment.

And we try to provide strategies to promote functional independence and participation in all areas of a child's life.

So we sometimes might also be making recommendations for equipment and other adaptations to provide support for children and also providing education to the adults, caregivers, parents in the child's life and in the community.

So some of the big things we're really thinking about no matter what it is that we're helping to support with, is general developmental level.

So what we know is for the most part when a child is referred to us for support they're often looking for support in an area where what we would expect to see for their age is different than what we're seeing, right?

So their developmental level might be a bit younger than their actual chronological age.

We also consider motor skills.

So fine motor skills, and a lot of the things that we do with our hands.

Gross motor skills, some of the moving around the environment stuff, and the coordination of both sides of the body or the motor skills that we're doing.

We also always take into consideration communication skills, both receptive, so what the kids are not understanding in the communication that we're giving to them and express it.

So, how are they communicating their needs and wants with us?

We think about behavior.

And some of the things that can be included in that can be compliance or distractibility, which also kind of relates to the cognitive skills, right?

And when we're thinking of cognitive skills we're thinking often about, executive functioning can be a big one when we're working with little ones who have autism.

And I'm sure many of you are familiar with the things involved in executive functioning, but being able to focus, shifting your attention from one thing to another, organizing, prioritizing, and getting your work started, right?

Regulating yourself.

Using your short-term memory, your working memory.

There's a lot of things that are going on there, right?

So we try to keep this in mind too.

So for today our big focus will be on dressing, mealtimes, and toileting.

So dressing.

Thought it might be good to start with what we might expect to see for kids at certain ages knowing that this varies a lot from child to child, but it can help us.

Really, when I look at this I think of it less as how old is a child and what should they be doing?

And I use this type of information more as, what should they learn before they learn something else?

So, as an example here, I might be thinking, okay, it doesn't matter as much to me if a child should be undressing between 12 and 24 months as it does that undressing comes before dressing, it's a skill we would normally see happen before dressing.

So I try to look at these expected, sometimes we'll call them developmental milestones or whatever, what we might expect to see from children.

I really look at those things in that way.

What comes before the next thing?

Or what comes before this thing that we really want to teach, and are the kids able to do those things?

So, as an example here, we're looking 12 to 24 months, children may be participating in dressing and undressing.

We might see them holding their foot up for you to put their shoe on.

Maybe they are taking their hat off or socks off or helping to push their arms through their shirts.

24 to 36 months.

Again, not worrying so much about the age there.

Undressing with little to no help, and there's more participation in the actual dressing piece.

So taking their coat off, putting on their coat, maybe using the flip over the head trick with their coat.

And we'll talk more about that if you're not sure what that is.

Kicking their boots off, finding arm holes in their shirt, pulling their pants down, those types of things.

By age four or after that list of things we just talked about or that I just mentioned, we see that kids are able to dress themselves most of the time, we see them starting to untie bows and maybe unzip zippers and those types of things.

And then between 48 and 60 months we see really, generally, pretty independent with dressing.

Their shoes are often starting to be on the right feet.

Maybe they're even learning how to tie their shoes.

They know the front versus back of their clothing.

They can turn the clothing inside out.

Lots of those different skills that we're not thinking about at the early steps.

So I hope that makes sense.

The next thing we really wanna think about is what is the goal?

And as occupational therapists, we are really thinking about functional goals.

And what that means is what is it that you want to see?

So sometimes when we get referrals, we'll get a referral that says, please do X, Y, Z.

And those referrals are really identifying what the intervention is or what somebody thinks the intervention might be.

And while that may be what the intervention ends up being, we really like to hear more about, what is it that you wanna see?

What is something that's not happening that we want to see happening, and framing it that way for us so then we can come in and we can work together with you to talk about what are some things that are already working?

What are some skills and strategies that exist?

How can we apply that to what we're trying to do now?

So this can be a really helpful question to ask right from the beginning because it can make things feel more manageable, it can help us be really specific and target our focus in one area.

So some of the goals might be, or some of the ones we hear often with this age group of littles is removing there...

We would like them to be able to remove their clothes independently or put their clothes on independently.

Maybe it's about using zippers and buttons, snaps, maybe participating in the routine of getting ready to go out on their own or participating the routine back into the house or classroom, from outside.

So you see, these are all very different things, and sometimes there'll be a bunch of goals mixed into one, so then we need to think, okay, where can we start?

What's the best place to start and what would have the biggest impact?

So some things to consider in general, no matter what we're talking about, what is the child able to do when there isn't any support given?

What is the child able to do when there is support?

And what does that support look like?

Now, what about at home versus school or school versus home.

How often is it that we might hear, geez, the child is doing this at school but they're not doing this at home or vice versa?

What's really great about that is then we can find out, so what is it that you do at home or what is it that you do at school that helps to make this thing happen?

And see, hmm, can we use some of those ideas and strategies in the other environment to help teach?

Now, let's think back to the things that we wanna keep in mind.

So we wanna keep the developmental level in mind, we wanna keep their motor skills in mind, communication, behavior, cognitive abilities, all of that stuff, right?

It's really great to get a baseline, to know what is it that kids are able to do at this point right now before we put any interventions into place and how will we know when things are going well?

So let's talk about some strategies for dressing.

And so what I've done here, this is not like an all encompassing list of strategies because we have 90 minutes and lots to cover.

So what I tried to do was think about what are the things, the common approaches or strategies that we use that are really impactful with these things.

And so you'll see this list come up as strategies that we'll be considering for the three different areas we're talking about today.

So the dressing mealtimes and toileting, and talk about how they each apply to those situations.

So one of the first things we'll talk about here with dressing is positioning.

Positioning is key and it can make a really big difference in what we're seeing for skills, which sounds sort of funny when you're thinking about dressing, maybe, right?

So think about yourself and if you're trying to put on a shoe and it's hard to get on and you need to maybe use a shoe horn.

For any of you who might wear high heels, having one heel on and then thinking I can stand on my one foot with my one high heel on while I put the other one on, especially if it's a boot or something, I can do that.

Or think about how hard it can be to get into clothes that are tight fitting.

So we wanna think about positioning.

So sometimes getting kids just to sit on the floor might be the easiest thing to do, or a small bench or a small chair.

Sometimes standing close to the wall can work too so that they can just put their hand up to help them balance if they already have some other skills with dressing.

So task analysis and chaining, another thing that we use.

So as occupational therapists, we use task analysis all the time.

It's one of our big go-tos no matter what we're doing, and this isn't an OT-only owned thing, many people use task analysis and chaining to teach things.

So we will spend a bunch of time here talking about this because it's really one of the things that could help us break things down into the smaller steps and figure out what those small steps are and where to get started.

So when we're talking about a task analysis, we're really talking about breaking the tasks down.

Nope.

Sorry, I'm gonna go back.

Task analysis is breaking the tasks down into the smallest steps, right?

So figuring out when I am getting dressed in the day, what does that look like?

And we're gonna talk about that more on the next slide, but we're thinking about all the steps that are involved in doing something.

It can be in a routine or it can be within just even getting your shirt on, right?

And then we'll talk about what's forward chaining, what's backward chaining, and what's the whole task teaching way to go about it.

So we'll get into those right now.

So a task analysis.

So what a task analysis might look like for getting dressed to go outside is like this perhaps.

There is no right or wrong order or number of steps.

Sometimes a task analysis might just have maybe it's taking your clothes off from outside, putting them away and coming into the class.

For some kids, we need to break that down even more.

And that may look like taking off your indoor shoes, putting your indoor shoes in your bin, getting your boots and coat on, sitting down, putting your boots on, putting your coat up, standing up, getting in the line to go outside.

We might need to break it down to those steps.

And sometimes we need to break it down to even more steps.

But for right now, for this example, we'll say, okay, here are all the steps that are involved in getting dressed to go outside.

It can also be helpful to do this for us and for kids, because sometimes when we say, okay, let's get dressed.

What does that mean?

Right?

Sometimes, whether it's get dressed, clean your room, whatever, get ready for bed.

What does that even mean?

We know what it means.

And sometimes we assume that kids know what it means, but it can be really helpful to really break it down and talk about what that looks like.

So in order to do a task analysis you might be able to watch your child do an activity and see what's involved.

However, if you're gonna be teaching it, maybe you wanna watch their sibling or another child, or you can go through the activity yourself and kinda keep track of all the different steps that are involved in that activity.

I've done that many times myself.

Okay, so we've got the list of steps.

We've done our task analysis.

We know what all the steps are that are involved.

And again, this can vary from child to child, it can look different.

One way of teaching is called forward chaining.

And that's where we would teach the first step in the chain before teaching the rest of the steps in the chain, right?

So we're gonna teach this first step of taking off their indoor shoes and then we're gonna help them maybe to do the rest of the steps.

Maybe that looks like us doing it for them.

Maybe that looks like them being a little involved in us doing some hand over hand with them through the remainder of the steps.

It sort of depends.

So in this case, we'll say, okay, awesome.

They've learned to take off their shoes, check mark.

We're helping them with the rest of the steps.

Now that they've learned it, we're gonna start teaching how to put their indoor shoes in the bin.

And then we're gonna do the rest of the steps for them.

Once they learn how to do indoor shoes in the bin, we put a check mark, and then we start teaching getting your boots and coat.

And so on until we get to the bottom of the list.

Now this can be one way to get started with it.

You know, there's different considerations depending on if you wanna use forward chaining or backward chaining, which is the next thing we're gonna talk about here.

And in backward chaining, you still have the exact same order but you're gonna start teaching the last step first.

So sometimes people will even order these backwards, right?

So what that means is in dressing we still have all of these same steps.

And what we're gonna do is do all of the steps for them and/or help them a lot.

And we're gonna teach the last step first.

Once they can do the last step, check mark, we're gonna go back from the beginning, do all the steps for them then teach them, stand up.

And then we leave them to go to get in the line outside.

And so on backwards.

Now what's sometimes helpful about using a backward chaining method is the kids get to experience task completion.

So they get to experience success and the task is over, versus forward chaining where they get to experience success but then they still have to keep on with the task.

You know, it's not that one is necessarily better than the other, but you knowing your kids and what might work best for them, and you might try one way and think, oh, this isn't working as well.

And go on to see the other one.

Then there's the whole task way of doing this.

And what that means is, you know, sometimes, and what you've probably found with your kids or the kids that you work with, is sometimes they can do a few different steps in the task analysis, right?

Sometimes they might be able to take off their indoor shoes.

They may be able to sit down without a prompt.

They may be able to stand up after they get their coat on and then need some help to get in line outside.

So what that means is, for the parts that they can do, we stand back and for the parts that they need help with we jump in.

And I'm not sure if this is like a popular acronym, but we used to call it MSG, so move in, squat, and get out.

So you move in, you squat down, you help and then you back out for them to do the parts they can do.

Then you move in, you squat, and then you back out, right?

So it's a little bit of a dance that happens there.

And yeah, that's another way of going about it.

And again, you might choose this, if you find, oh, the kids skate, we need some help with a few areas, but they have a few areas.

So now talking about prompting.

Prompting is something we use.

I mean, I'm sure we all use it whether we know that we're using it or not.

There's so many different prompts and way to prompt, so this isn't a presentation about prompting, of course.

I did include a visual.

Now the other thing I'll say, there are a couple of different prompt hierarchies out there depending on what you find.

Sometimes the order in them is a little bit different.

But when I look at this one, what is really standing out for me as an occupational therapist and when we're talking about increasing skills, independence in skills of activities of daily living, we're really looking at using the most prompting, the most invasive, as they call it prompting and moving to the least, generally speaking.

So what we also wanna say is when we're using the most full physical or partial physical prompts, we're trying to do that from behind the child.

And sometimes that can feel a little bit awkward.

And why do we do that?

Well, we try to do it from behind for a couple of reasons.

Number one, it's easier to get your hands over theirs in a way that, picture if you're trying to help them pull up their snow pants and you're behind them and you've already got them on their feet, putting your hands over theirs.

'Cause if you're gonna do it anyway, I mean, why not?

Putting your hands over theirs, teaching them.

You put your thumbs on the inside, your fingers on the inside, you hold and then you pull up.

It really helps them get to feel like, this is how I do my hands, this is how I hold them.

This is how I pull it up.

And it's easier for you from behind to actually help position their hands in the right way, because it's more coming from the angle that you would be doing it as well, right?

If you were doing it yourself.

The other thing is, it's much easier to fade somebody out because we don't want you to have to be there forever.

It's much easier to be able to fade somebody out if they're behind, right?

And we wanna say, we want to try to talk as little as possible.

Now you will see that verbal prompting is often more towards the less invasive side of the prompting thing.

And you might think, well, why wouldn't we wanna do that?

And we talk and we wanna use communication.

What can happen is when we're using verbal prompts and we're like, okay, put your shoes on, put your coat on, put your pants up, dah, dah, dah.

What we often see can happen is once we take those verbal prompts away it could be really tricky for kids to just go to doing things, like it's a lot harder to get rid of a verbal prompt than it is to get rid of a physical prompt.

And so when we're talking about independence with activities of daily living, we really want to get in there with the physical stuff.

And it's easier to feel like, oh, you can start to feel when kids are getting their coordination.

When they're being able to pull things up, when they're ready to move on it can be a lot easier to do it that way.

And then, obviously we're sometimes gonna use modeling where depending on what's appropriate, where like we might put our clothes on or put our shirt on and the child's watching us and then they might do it.

Or we might button our snow pants and then they might button their snow pants or their friend might button their snow pants.

And then they button their own snow pants, perhaps.

In a gesture, when I might just point to the items for you to put on.

Verbal.

Well, we know what that is, right?

And then visual, it can be just the location of where clothes are set up.

It acts as a bit of a prompt.

It can be an actual picture, multiple pictures.

It can look like many different things.

It can be a picture of the actual items.

It can be a symbol that represents the items.

It can be one of those more cartoony looking images that you often see if you ever use Boardmaker or something like that.

There are different types of visuals that might be used.

So on the note of visuals, here's an example.

So Do2Learn is a great place where you can get some freebies.

And I got this freebie from there.

So just an example of a visual that's already made.

Now, this visual might be static where I just print this off, I have it and I point to the different pieces, or I physically prompt the child to point to the different steps, as they're doing the steps, I'm pointing to one step, like take off PJ's, then you take off your PJ's, pointing to the next step, put on your underwear, you put on your underwear.

Another thing that might happen is there might be Velcro on these, so you can pull the picture off.

So you might be like, okay, we're gonna point to take off pajamas.

I'm gonna take off my pajamas.

And then I'm gonna remove the picture of pajamas and then that helps to show me how many steps left.

Pointing to putting on underwear, then you put on your underwear, you remove the picture of putting on underwear.

That's another way to do it.

And you might see them lined up in a horizontal line.

You may see visuals in a vertical line.

You may see them with words or not with words, there may be check boxes.

I'm not as big of a fan of check boxes for dressing because then they actually need to like have a pen or something to do that and that sort of doesn't seem like it makes as much sense, but for some kids, it may.

So again, the point just being, it can be whatever you think, whatever can be helpful.

Now, Lessonpix is another great place to get visuals.

I'm not paid by any of these people, so I should just let you know that now.

But there's lots.

And there's already like a pre-made things that you can get, and the fee is pretty affordable.

So that's another great place to get some options.

Anyway, there are so many ways.

I know I mentioned this earlier, but just for sometimes for some kids you actually need to use the real pictures of their actual snow pants and their actual boots.

The actual cubby area.

And so just keeping that in mind too.

And other specialists can help you figure that out if you're not sure of the SLP or whatever, there'll be different people who might be able to help you figure that out.

So practice.

I know this seems like a simple one, but it's a big one.

So, well, we know that classrooms are busy, especially if we're talking about, oh, time to practice it in classrooms and the days are full.

And you know, what we're really hoping with any of these strategies is that you're practicing during the times that you're getting ready to, say in this case, go outside.

And by practice what that might mean is well it can be a lot faster sometimes for us as adults to just get kids ready and send them out the door.

We're not really working on increasing their skills with independence and activities of daily living, right?

So when that's happening, it might seem better in the short-term, but in the longterm we might not be building those skills or supporting the building of those skills as quickly.

So if we're gonna do it anyway, why not just do some physical prompting and get our hands in there and help kids out if we can.

Sometimes you might be able to, if resources and time allow, get out into the hallway a little bit before other kids get out there, or maybe wait until kids are going out and then get going, or something like that, having a space or time where it's less distracting can also be something that's helpful as well.

Or at home, you know, thinking leaving extra time in the morning before getting dressed, or maybe we're really practicing dressing at night when we're not on a schedule and it's a little bit easier to do it.

And in the morning, I just do it for you as your parent or your caregiver.

You know, maybe recess is easier to spend some time practicing than lunchtime.

So making it work for sure, however you can.

And allowing the child to do what they can on their own.

Sometimes as adults helpful, helpful adults, caregivers, we can really kinda jump in there pretty quickly and try to get in there to be supportive.

And so really allowing them to do what they can on their own is super helpful, especially as they're developing their skills.

And having a plan.

So, if this is a skill that's being worked at home and at school or at school, and maybe there's different people supporting, really having an idea of like, what are we working on right now?

Where are we at with it?

And the reason that can be helpful is because we want people to sort of be on the same page, not sort of, we want people to be on the same page and using the same approaches and having the same expectations so that kids are really clear on what they need to be doing and we're able to support them in the same way.

Reinforcement.

The next piece, the biggest piece.

I mean, we know, right?

Reinforcement is critical.

It's so, so, so, so, so important.

And no, kids won't become addicted to reinforcement as long as we get rid of it as they start learning, you know, slowly getting rid of it, giving it a little less as their skills improve over time.

But think about it, this is hard work, right?

This is really hard work.

So we need to make it worth it for kids.

The big thing around reinforcement is making sure that it's something that you know they really, really, really want as best as you can and trying to limit their access to that reinforcement, whether it's a toy, whether it's an activity, praise, a special treat or something, trying to make sure it's something that maybe they wouldn't be having access to all of the time 'cause that helps keep it a little more powerful.

Now, sometimes we need to change reinforcers up, right?

We all know the kids who every day maybe have something different that they want or that they'll go for.

And so, you know, keeping that in mind, we need to be creative at times too.

And there's lots of great different ideas.

The families and school peeps that I've worked with teach me all the time.

And it's incredible.

So you get a couple of minds together and we can do a really more official way to assess what might be a motivator or reinforcement for a kid as well.

And again, you can learn ways to do that too.

But just being creative and trying to think and try some things out.

So we're gonna watch this and then I'm gonna get you to move, and give you a little quick little movement break.

So we'll watch this and I'll tell you what your movement break will be.

(lively music) - One of the easiest ways to teach your kiddo how to put their jacket on by themselves is to start with the hood, it's 'cause it's easy to find, you can hand it to them or maybe it's hanging on a hook by the hood.

Have your child put the hood on their head, and now it's in place and they can just put their arms in the sleeves.

And done.

- The second method we're gonna talk about today is the lay-on-the floor method, or at least that's what I'm gonna call it for now.

So you lay the jacket on the floor with the hood facing towards the kiddo.

And the hood can either be tucked in or out.

Or if the jacket doesn't have a hood, this is a really great way to teach it as well.

So what the kiddo has to learn in this method is first of all, obviously, to lay the jacket with the head facing towards them.

Secondly, where the arm holes are, they just stick their arms in the arm holes and then you can wrap it around and go over.

Ta-da.

Or additionally, I've seen a lot of kiddos flip it over their head and they find that kind of fun and entertaining as well and a fun way to get their jacket on.

We hope.

- Okay, so I'm gonna give you a few minutes.

I'm assuming you're either at home or wherever you are you probably have your coat with you because it's cold outside.

We've got that beautiful snow up there.

And maybe even if you're not here, it's getting to that time of year where we often have coats in North America anyway.

So what I want you to try is both of those ways of getting your coat on.

So I'll give you maybe three or four minutes to go try that.

And then when you're back I want you to let me know which one you prefer when you are thinking about teaching kids, and why?

And you can just put that in the chat.

So go ahead, give that a try for however long it takes.

And then when you come back, please, type in the chat if you're willing to share.

Which do you prefer teaching a kid, and why?, I just want you to try it for yourself to see what you think.

I actually can see the chat, Shelly.

So I'm seeing some people have tried it and/or are sharing with us what they prefer.

And I see somebody had said earlier on, I'm guessing, and I didn't see that earlier, that shoe tying and zippering of the jacket were things that they wanted to talk about.

And if we don't talk about those things specifically here, I'll send you a couple of links to some easy, easy videos that are super helpful.

I can get Shelly to share them with you too.

So let's see.

So laying on the floor, flipping over the head.

And Lindsay, if you're still there, and you can let us know why you prefer that, I would love to hear.

Joanne is saying the hood, easier for a child that is blind.

That's a great point, Joanne.

Vanessa saying, prefer to put the hood on first and then put my arms in.

I think in an elementary school hallway all those sinking coats would cause some trouble.

That's right.

Plus lining up the hood facing them would be an added challenging step.

Yup, absolutely, that's definitely something to consider, especially if we're in a hallway with a bunch of kids, for sure.

Laying it on the floor seemed easier, but I wondered about hitting others with the coat, Kelly says.

Yeah, and I mean, again, if we have the space and we're able to do that, that's great.

I wonder how often we would be getting all kids to do this at once.

But the point being, if we're teaching kids to do this and they'll start doing that, what does that look like?

So, yeah.

Nope.

That's great.

The whole process is exciting for a lot of my kids, It's reinforcing in itself.

That's right, Lindsay Hay, especially if that means you're going outside from there.

Thank you everybody for sharing, I appreciate that.

All right.

Oops.

Okay.

And actually, why don't we talk...

So, shoe tying, I'll get to Shelly.

I'm gonna make a note for myself to share a link with you.

It's a really cool link that a few of us OTs started referencing a few years ago.

So shoe tying.

And as for zippering, what I can tell you is there's different ways to think about this.

So sometimes people will say, well, can a child open and close the zipper on, say, a pencil case or whatever.

I always feel like it's helpful if we're doing it on an actual piece of clothing and from the perspective that we would be tying it up or zippering it up.

So first, what you can try as a first step in teaching zippering is laying the coat on the floor, on their lap in front of them and showing them, you wanna have your thumbs up on both sides.

So you wanna have each half of the coat.

So let's pretend the coats on its back, we have a zipper.

You wanna have your thumb on the top and your fingers on the bottom, your thumb on the top, your fingers on the bottom on both sides, right?

And you want it to be on the zipper part or really close to the zipper part.

And then you want to talk about, sometimes we'll say, oh, we're going to feed the zipper.

You know, so then you push it in and then we show them to hold and pull.

It's really hard, I know.

I'll send a video link, thought that will be helpful.

And then pull the zipper up.

And then once they kind of get it that way you can put it on their body.

And again, same thing, thumbs out, fingers under, feed the zipper, you're holding and you zip up.

The other thing we can sometimes do if we're not even at that place of the latching, even before latching, we might latch for kids and show them again, the key part that we often forget, get them to hold the bottom of their coat with one hand, thumbs out, fingers in, because we'll want them to do that and then pull the zipper up with the other hand.

Sometimes we'll put a zipper pull on there.

You can use like a key ring just to make it bigger, easier to grasp for kids who fine motor skills are still developing.

So I hope that's helpful for the zippering.

And I'll include the link for shoe tying.

Oh, let's see here.

My coat does not have a hood just to color.

I prefer the hood way for ease but see the limitation with hoodless items.

Yeah, I know.

That's a great point, Melissa, thanks for sharing.

Okay.

Mealtimes.

So we're gonna kind of go through the same thing again, and I know you're probably thinking, oh geez, how are we gonna get through all this?

We won't go into the details this time about what it looks like to do a task analysis and chaining 'cause we've already talked about that, but we'll look at some examples.

So with meal times, again, what we might expect to see around 12 months they're finger feeding.

And again, let's not even worry about the month, let's talk about what comes first.

Finger feeding easily, chewed foods, drinking from a cup with the lid.

Then we might see using a spoon, but it being messy.

Then we might see using a spoon, stabbing with the fork, starting to do hand washing before they eat meals, helping to set up the table.

Then we might see using utensils with a little less mass, increased independence with opening and closing containers, zippers on bags, things like that.

Maybe the next after that we would see cutting with a knife and independent with managing utensils and all table foods.

So again, knowing the expectations and knowing kind of what we might expect to see could help us figure out, we really want this kid to be super independent, where are they at?

Like can they use this spoon yet?

Can they help with setting up the table?

What does that look like?

So what are the goals?

We need to think about that again, right?

Do we want them to be independent with meal time routine?

Do we want them to feed themselves independently with utensil?

Do we want them to stay seated during mealtimes?

Probably we want them to do all of these things.

Then thinking about what's the biggest bang for our buck?

What would make the biggest difference?

So it's really important to kind of break the steps down and think about what it is that we're looking for.

Because being independent with the routine would involve like them getting up from their seat, going to wherever their lunch bag is, getting that, bringing it back, sitting down, right?

Versus staying seated during mealtimes.

Maybe they could do that other stuff and it's just hard for them to sit or maybe that's where we want to start, or perhaps it's even for them to be able to feed themselves independently.

So things to consider.

What can the child do?

These are familiar questions from before, right?

What can they do when there isn't support?

What does it look like when there is support?

What does that support look like?

Home, school?

Now, some of the things that we might see that can have an impact on mealtime behaviors, whether it's eating or the actual routine can be, are they hungry or not?

Like, are they a grazer?

Do they drink a ton of juice and milk if they're not hungry?

Why does that matter?

Because well, if we're not hungry then we're less motivated to join into the routine, right?

Some of the kinds of things that we also think about is really like main meals should be 20 to 30 minutes max, snacks should be 10 to 15 minutes max, and trying to avoid distractions at mealtimes too, right?

Like TVs, tablets, phones, whatever.

And sometimes we understand you have to start with that stuff, sometimes, and that's the only way, but really having a plan about how we get rid of that stuff during the meal time.

So, and again, let's think about from a developmental perspective.

So we're thinking about that list that we just looked at about what comes.

You know, so we would expect a kid to messily be feeding themselves with a spoon before they're cutting with a fork and a knife, for example, right?

Motor skills.

What do they need?

They need to be able to use their hands together.

They need to be able to pick things up and put them down and move things around.

Communication.

Do they know what we're expecting?

Do they know how to ask us for help or tell us when they're having a hard time?

Behavior.

Again, just the same as before, right?

Is there some other behavior stuff that's happening here.

And then cognitive considerations.

So what's their attention like?

How long can they sit for?

Are they able to regulate themselves to be able to be at the table?

Can they plan their meal and organize it and get things out as they're going?

So again, really great to get a baseline started to see where we're starting from so that we know what we need to do next to move forward.

So when we're talking about some of this stuff, going back to looking at these steps again, too, so positioning being one of the first ones.

Table and chair height and proximity to table.

So it's really common at the beginning of the school year, we might walk into a classroom and the kiddos, especially the primaries or ones are still so petite, right?

And the tables and chairs can sometimes be a bit too big for them, but then by the end of the year they've kinda grown into it.

And some of that is out of our control, right?

And at home, what do we do once we're no longer in a high chair and then we want them to sit at the family table.

And then sometimes you see that height can be a bit of a tricky thing there as well.

So what we really want to see is that kids are close enough to the table to be able to access the things they need, but not too close if they can't move.

So sometimes we tuck kids way in there.

So if you picture yourself tucked way into the table, that's kind of awkward as well, right?

So not too far though either so that they're still able to grab stuff.

We really wanna be thinking about them being at 90, 90, 90, we say.

And what that means is a 90 degree angle at their ankles and a 90 degree angles their knees and a 90 degree angle at their hips.

And then for their elbows, when they're bent at their sides, to be within the range of the top of the table.

An inch below or above is a great way to kind of look at it.

Now what happens when we don't have the furniture we need to make this happen?

Again, creativity.

We have so many people that are so creative and that are able to figure these things out.

So sometimes we end up putting a stool under feet.

Sometimes, if we get a little bit of a higher chair that we need and then a stool under their feet, or even textbooks, like baskets, we've used so many different things to make sure that we're able to do that.

So positioning is huge, and that can actually make the difference on its own, just by itself, right?

So I'll get you to do an activity in a few minutes just to see about the impact of positioning, 'cause that really can have an impact on the whole rest of the mealtime.

Task analysis.

We just talked about this and chaining, right?

So breaking the task down into the small steps again.

We just talked about what all of this means.

Now, in this example, perhaps a task analysis might look like getting their lunch bag, bringing it to the table, sitting down, unzip and open lunch bag, removing the item, opening the item, eating the item, putting the garbage in the can, putting the items back in the lunch bag, zip lunch bag, get up, put the lunch bag away.

Now I know these were a lot of steps, and sometimes we need to break down those steps into even smaller steps.

The reason I list them all is just to really highlight the point that there are a lot of steps, it's not just a matter of sitting and eating, right?

So back to our example of forward chaining, that this might be a way that we teach these routines if we're looking at teaching the routine, right?

So maybe first we'll teach them to get their lunch bag and we'll do the rest for them.

You know, maybe we'll use backward chaining.

And the first thing that we'll teach them is to put their lunch bag away and that's where they have success first, and then once they have that we teach them the getting up and putting it away, and getting up and then letting them put it away and so on, just like we talked about the last time.

So this same strategy, 'cause I know routines are a thing that I'm often pulled in to support.

It's just like, oh geez, how did we do this?

How did we get there?

Like this is just bananas, right?

We also want to make sure we're ...

I'm sorry, we'll go to whole task force.

So the whole task teaching, again, maybe there's steps they can do.

Oops, I have the wrong slide here.

So picture this list with a few different check marks in it.

And it's the same idea of jumping in and jumping out when kids need help or when they don't.

One of the things I also wanna mention about mealtimes is.

Sorry, I've just got distracted, there's people talking in my office.

Sorry.

We'll skip that for a minute, we'll come back.

Anyway, prompting, let's talk about prompting.

So again, we've already talked about prompting, the different types of prompting.

Again, these are things that we consider for meal times as well.

Like would visuals be helpful?

You know, would it be helpful to physically prompt them?

Would it be helpful modeling?

And, and the nice thing is a lot of times in classrooms or with siblings or with family, modeling is an easy thing to do at mealtimes, right?

Because you're all sort of going through the routine together, you're eating together.

And again, the same tips apply.

So, most to least often, from behind if we're trying to help do something hand over hand at first can be really helpful, and trying to talk the least amount as possible so that we don't have an additional prompt to fade out.

So same kind of approach to this as we would have to dressing as a really general, basic place to begin.

And again, the visuals as being a very specific type of prompt.

So perhaps a mealtime may look like this, perhaps it'll have different steps.

Perhaps there won't be check marks.

Perhaps there'll be real photos, again, just like we talked about before for dressing.

Practice.

Practice.

Really want to leave extra time to practice mealtime routines, right?

So again, sometimes that means starting a little bit before, or just being really patient if we're waiting for something to happen or if we have to break things down or provide a little bit of support, right?

And again, letting the child do what they can on their own.

Instead of doing it for them, helping them by using hand over hand.

One of the things that we'll also say is, if you're going to help a kid open a container or zipper or a baggie or something, I always just say, you know what, if you're gonna do it anyway, why not put your hands over theirs and start showing them right away how to do it?

Why not?

If you're gonna do it anyway, it gives them a little bit of extra practice and it starts really teaching them, this is how I use my hands together.

This is how I hold things.

This is how I move things.

You know, when it comes to feeding yourself independently, one of the things we'll hear people say as well, they're still really having a hard time using a spoon, and we'll ask, well, what's the hand that's not using the spoon doing?

And a lot of times when you look at that hand, it's just kind of down on their lap or something.

Get them to hold the dish, the bowl, the container with the other hand to help stabilize it, and keep it still and then they can use their spoon.

We really wanna be thinking about things like that too.

And again, reinforcement, can't say this enough, right?

It's part of everything that we do.

And there's so many natural reinforcers for us as adults in our lives, we don't even think about it, right?

Like your paycheck for the end of the work week is one really powerful example or like loyalty reward cards, right?

How often do you go to a place to get coffee where you know the seventh or eighth one you get is gonna be free.

It happens a lot.

So take a minute.

So if you have in your house or wherever you are right now, and maybe you don't have this, so if you can't do it just kind of try to picture it.

But if you have a high table that you use, like stool style chairs, try to sit at it with a low chair.

See what that's like.

Or at your dinner table, just go and like do a high kneel in front of it.

Not so that your bum is touching your ankles, but so that you're just on your knees, but you're up straight, if that makes any sense.

And try to picture what that would be like if you had a fork or a cup or something and just give it a try.

If you don't have access to those types of things right now, maybe just think about it in your head and think about what are some of the questions or thoughts that come up in your mind in terms of like feeding yourself?

What do you notice?

Because again, positioning is so important, right?

Energy is going to balancing.

Yes.

Exactly.

And what does it like when you have a table up to your chest and you need to eat.

So here's my table.

Picture like...

Unstable, yes, Charlene.

Exactly.

Unstable, yeah.

What about like how your body is in relation to like the utensils?

How awkward would it be if as an adult, we sat at a gigantic table that was like up to our chest and we were trying to feed ourselves, right?

And again, it's not because the other things are important, but that has such an impact on everything.

Awkward, trying to keep your elbows up high.

Thanks, Lindsay.

Yeah, like, it's just super, super duper awkward.

It's not efficient.

It's uncomfortable.

It can distract us from what we're actually there to do.

Can't see the food.

Exactly, right?

Like totally, that's totally another thing that happens.

So just thinking about that and thinking about, so what can we do?

We're thinking, oh no, what about the dining room table at home and our little kids and just take a look at them and think, how can I change this?

You know, sometimes people use booster seats and then a stool or something else under so that their feet are on.

Cause that's what happens, right?

When you increase the height of the chair or where their bums are in relation to the table, then their feet are dangling.

So what do you put under the feet?

It doesn't have to be a big, fancy thing.

Does not.

It can be anything.

You can be creative, whatever you see.

Sometimes parents use cushions from the couch or pillows or whatever, but just thinking about that and positioning yourself and how that has an impact on everything else as well.

So especially if you're thinking like, what about like, how motivating is it to even do the routine to go sit at the table when you're like, oh my God, it's so much work to sit at the table and I can't see my food and it's really hard and I can't do anything like...

That can have an impact even just on getting the routine to get to the table.

So hopefully that makes sense.

So the last area we're gonna talk about is really around toileting, right?

And what we might expect to see.

So what we might expect to see first is some control over bowel and bladder.

You might start to see that, right?

Next thing you might see is some control during the day, maybe they're pulling their pants down.

Maybe they're sitting on the toilet.

Maybe they're able to let us know that they need to pee or poop or after they have, maybe next after that you might have some control at night.

Maybe, that being said it can still happen that you'll have some nighttime wetting until seven or eight years old on occasion, right?

And that's still within normal.

So just keeping that in mind too.

And we wouldn't expect to start working on nighttime training until kids have been at least successful in the day, successful being without accidents for at least a couple of weeks, pretty solidly.

So just keeping that in mind.

And then between four and five we expect full independence, right?

That's kind of where we get to at that point, even being able with the clothes, with everything, with peeing and pooping, the toilet, the clothes, all of that.

That might be what we would be expecting.

And washing hands as well with maybe some reminders.

So again, just showing what you might see there.

So what are the goals?

Let's think about it.

Do we want them to pee in the toilet?

Do we want them to poop in the toilet?

Do we want them to ask or indicate the need to go?

Because sometimes we'll see that kids will be trained to pee or poop in the toilet without being able to tell us that they need to go, right?

They're on a schedule.

Are they able to do the whole thing but they're still not wiping.

There's so many different goals that we might hear.

And I guess I should have told you earlier, pee and poop are common pieces of my vocabulary.

And so I do say those a lot, and you'll probably hear it a lot in the next 20 minutes or so.

So really again, I'm thinking about positioning, and we're gonna get into that.

Some of the questions I get asked a lot as well is around what kids need to be able to do before they start toilet training.

A myth or a few myths are the following list.

In order to be toilet trained a child must be able to sit for five minutes.

No.

In order to be able to be toilet trained a child must be able to pull their pants up or down.

Nope.

In order to be able to be toilet trained a child must be able to tell us that they need to go to the wash room.

Nope.

In order to be able to be successfully toilet trained they need to be able to follow all simple instructions.

No.

So that's not true.

We can still do toilet training with kids who aren't meeting all of those expectations.

That's absolutely true.

Done it many times.

And so, again, back to the list of things we can consider, we always wanna know the answer to these questions.

We wanna have a baseline, right?

What does it look like at home?

What does it look like at school?

What does it look like with support?

Without support?

Does it look like anything at all?

Where do we get started?

Also, I get asked the question about potty versus toilet.

And one of the things that I often say is when you're thinking about that stuff, potties can be really convenient because they can be located kind of anywhere.

They're very portable.

I've had some families who are going on road trips and they bring the potty with them, pull over and get the kids to use the potty if they're going for long road trip, right?

So it's not to say there isn't a place for them, but what I'll often say to families who are getting started and when they're considering potty training is try to go for the toilet right away.

I know that's not as convenient and it can be trickier.

It's just that sometimes what will happen is kids will learn on the potty and that's great, but they don't necessarily generalize those skills to the toilet.

So what does that mean?

Well, that means sometimes we have to go and teach toilet training fully on the toilet again.

So thinking about that and thinking about how tricky that is, we may wanna start with the toilet first.

And again, every everybody's gonna make their own choice, but that's kind of one of the points that I make to consider.

The other thing is around pull-ups versus diapers versus undies.

And I say, if you can do it, go for the undies.

Yes, let's do it.

At the very least, we wanna have kids in pull-ups before that.

And it's okay, like ideally, kids would be in undies the whole time they're toilet training, right?

But realistically, for families that doesn't always work.

And what will happen is if we say, yep, you need to be in undies all the time, one of two things will happen.

Families will either not go out anymore because they're worried about the kids having accidents everywhere.

I'm sorry, one of two things happen.

They will either not go out anymore or they will...

Sorry, I keep getting distracted.

I'm in a cubicle area and we have like many people coming and going so it's a little bit distracting.

But yeah, or they would just won't do toileting at all.

That's the other thing, right?

'Cause it's just too hard.

So I'll say like, yeah, absolutely, if we can have them in undies, a lot of the time when they're ready to go, let's do that.

But if you want them to still, of course, overnight, diapers or pull-ups or whatever, overnight.

And if you're going out, put them in a pull-up, still go out, still do your thing.

But just some of the common questions that come up.

So those are some of the many things to consider.

And then let's not forget, like developmentally, what are they doing?

Like, are we expecting the right things for where they're at developmentally?

What are their motor skills like?

Especially as they relate to the dressing and undressing piece, right?

What about communication?

How are we gonna work that communication piece into the toilet training?

Any behaviors that might be related, and then the cognitive piece, right?

Planning, organizing, getting through these routines, shifting our attention to different things, knowing that I have to go or not, which can be related to interoception.

And we'll kind of talk about that in a quick minute.

So first we wanna be able to roll out any medical concerns, right?

There can be digestive issues.

Sometimes digestive issues turn into washroom issues, which sometimes turn into refusal to go to the washroom.

There can be other medical conditions that can have an impact.

We wanna think about any dietary restrictions, right?

How much fiber and water and moisture are we getting in food?

How much activity are we doing?

All of these things can have an impact.

And so, you know, knowing about these things and thinking about these things are really important.

And that brings up one of my favorite charts.

Here's the Bristol stool chart.

And what we're aiming for is type three or fours, right?

That's ideally what we're aiming for.

When we're into the type 1 or 2, that's when we're seeing constipation.

And then when we're at type 6 and 7, that's really when we're seeing diarrhea.

And why does this matter?

Well, a couple of reasons, if kids are experiencing a lot of diarrhea, we're kind of setting them up for failure if we start doing toilet training, right?

Because they're probably often not going to make it on time.

And if it's constipation, what we might be doing is teaching them to hold even more.

Right?

Because that's what we're doing into the training.

We're teaching them to hold.

So if there's already an issue with constipation, we might be increasing that issue.

Sometimes the other thing that we'll see is that we'll see, they'll say, well, there's little poops in their diaper pull-up like all day or there's little amounts and sometimes you just wanna make sure that we're ruling out if a kid's impacted or not.

If there's a whole bunch of stool just sitting there, not coming out, especially for kids who aren't pooping frequently.

'Cause sometimes even when you're seeing little bits come out in the diaper they might still be constipated 'cause little bits can leak around a really impacted area.

So you wanna really keep that in mind too, right?

And just knowing that those things can really have an impact on training, especially bowel training.

So we always suggest get those things sorted out first, see your doctor, rule out any other challenges.

And it's also the other thing that we might see, is kids might become toilet trained, and if they have a bout a constipation or diarrhea, it can kinda set things back a little bit too, right?

So knowing that can be something as well.

So we just really wanna make sure that we're coming out with the type 3 and 4 bowel movements as much as possible.

So interoception, on that note.

So Kelly Mahler's an OT and you've may have heard of her before.

And she's really the expert in interoception.

I am not.

Interoception can be tricky to use with kiddos who are really young 'cause it requires some cognitive abilities to be able to sort of understand it and move it, but really what it is, is the awareness or the ability to sense or interpret what's going on inside of our bodies at any time and knowing how to respond to that, right?

Being able to identify and respond.

So earlier when we started this, I was like, ooh, I don't know if I'm nervous or excited 'cause in the body nervous and excited kind of feel the same and then I have to use other strategies to figure out what it is, right?

So for kids, when we're talking about toileting, or considering like, do they know if they need to go pee or poop?

Like, can they sense that that's even happening?

And one of the good tips that I often say is when you see kids hiding, they probably have a good sense that they need to go, right?

On the other hand, kids who have experienced a lot of constipation may have lost the ability to really feel when they need to go.

And if they've had a history of being really, really constipated.

So yeah.

Positioning.

Again, anybody surprised we're talking about positioning again.

So we already talked about potty versus toilet.

So positioning really what we say is to make sure that their feet are on a solid surface, so oftentimes for littles, that means a footstool of some sort.

And then making sure their little bums are secure as well.

So when you think about that.

And this again it is the first step.

It is the most critical piece because if they're not solidly and securely positioned it can cause a lot of problems.

We've had little kiddos who maybe without a reducer ring have fallen into the toilet, and that can be very stressful or traumatizing experience for some kids, right?

So we just wanna make sure that they're set up well for that.

Imagine yourself on a giant toilet, if you can, where your feet aren't touching and the hole is massive and you had to poop, how easy would that be?

When I've tried to picture that, I think it would be really tricky.

I'm just gonna check and see.

Okay.

So strategies.

Back to the task analysis.

And again, breaking the tasks down into the smallest steps.

Maybe we'll do some forward chaining.

Maybe we'll do some backward chaining.

Maybe we'll do some whole test teaching, who knows?

It'll depend on what we're looking at, a routine versus the actual individual pieces, right?

So if we're looking at a routine, doing the routine of the washroom or toileting, getting that down.

A task analysis might look like this.

These might be all the steps.

And again, toilet training is about so much more than just peeing and pooping in the toilet.

There are so many pieces.

I need to be able to know that I need to go, I need to get into the washroom, I need to be willing to wear undies, I need to be able to sit down on the toilet for long enough to let the pee or poop come out.

You know, there's hand-washing, the flushing, the wiping, there's so many parts.

And so when families get to the point where their kids are willing to wear undies, go into the bathroom, sit down.

I have kids that will get their own reducer ring and footstool and they get all set up and they're there and they're ready, and they're waiting, but they're just not peeing or pooping in the toilet.

When that happens, I say, oh my gosh, you're so close.

Right?

You're so close because they're just not doing the peeing or pooping piece.

And that's just one step in the whole thing.

So forward chaining might look like this.

Again, just to hit the point home about that for the routine.

Backward chaining, maybe it'll look like this.

Whole task.

Maybe these are the things that they can do.

One of the big things that often comes in to toilet training is around the different pieces that sometimes need their own individual work.

So one thing I will note is generally speaking as just a little side note, we wanna make sure the biggest thing that we wanna make sure of before we start toilet training is that kids can stay dry, clean for like one and a half to two hours at a time, more often than not.

And how do you know that when they're wearing diapers or pull-ups?

We can just take a peak every 30 minutes or so, and put a check mark or an X.

Check mark if they're clean and dry and X, if they're not just to kind of see.

And then over the period of a few days you can look back and see yep, way more often than not.

They can go one and a half to two hours consistently staying clean or dry.

If not then, 'cause that's kind of my one sticking point.

If they're not, then they're probably not quite ready, physiologically, right?

And so that's something we wanna keep in mind.

Anyway, here are the things that we're often working on.

Excuse me, when it comes to the early steps of toileting.

So we'll often say like, let kids go into the bathroom, let them see you in there.

Let them be around it, let them be comfortable in there, let them participate in hand-washing, whatever.

So one of the first steps might be the wearing undies.

Wearing undies can be super duper tricky for kids.

And it's just such a valuable step in the toilet training process because the whole experience of actually peeing or pooping in your underwear is very different than if you're peeing or pooping in a diaper or even a pull-up.

Pull-ups are so absorbent.

And there are many children and families that I've worked with over time where that alone is motivation enough to pee and poop in the toilet.

So just something to keep in mind.

Now, sometimes kids don't want to wear undies.

And when you think about it, if you've been wearing diapers or pull-ups for the first five years of your life, and that's where you've always gone pee or poop, number one, it can feel really different not to be wearing a pull-up or a diaper.

Just that feeling.

That's a huge adjustment.

Secondly, oh my gosh.

I'm not toilet trained yet, what do I do?

I don't have my diaper or pull-up on.

So anyway, just kind of keeping that, that's an adjustment in and of itself.

So wearing undies, what might we do?

Well, we might use shaping, well, what is shaping?

Shaping is a technical term is reinforcing successive approximations toward the target.

So what that means is reinforcing steps that are close to what we wanna see.

So in this case, what that might mean is, I want my kid to be able to wear undies and they're refusing.

So my first thing I'm gonna reinforce is if I can get them just to put their undies on for like a second and give them a reinforcer and then I'll let them take them off.

Woo-hoo, we're doing it.

That's one step closer to wearing undies full-time.

Once my kid gets comfortable with that, no big deal.

It might be putting them on and leaving them on for five seconds.

Reinforcer, taking them off.

Woo-hoo, awesome.

And so on, slowly and slowly until they're comfortable wearing undies.

And sometimes that's what we have to do.

Sometimes you only have to do that for a few steps or a few increases in lengths of time.

Sometimes you won't have to do this at all.

Sometimes you'll have to do lots of steps, but it's super effective.

Going into the washroom.

So how hard is it to do toilet training if the kid won't even go into the washroom?

So sometimes it's a matter of like walking in, reinforcer, walking out.

Sometimes it's just getting to the door, reinforcer, getting out.

Sometimes it's walking in, staying in for a few seconds, getting out.

Sometimes it's walking in, washing your hands, leaving.

You know, sometimes it's walking in, standing by the toilet, whatever.

Sometimes it's being in there when other people are in there.

It depends on what that's gonna look like.

But just being in the washroom is really important.

Now sitting on the toilet.

I would love to hear from you.

So now that we're on this topic, wearing undies, we kinda went through what that might look like, going into the washroom, what that might look like.

What might be a way that you would approach sitting on the toilet.

So my kid won't sit on the toilet, I need them to sit on the toilet.

How would you maybe use some shaping to do that?

What could that potentially look like?

If you wanna put that in the chat box or the Q&A.

And what I'll say is when you're using shaping, once they'll put their undies on and take them off and you reinforce it, you got that step.

And now the next thing you wanna reinforce is them wearing them for a bit longer.

You no longer reinforce them for putting them on, you only reinforce them for wearing them longer.

And once they wear, the next approximation is to wear them for even longer.

You know, they've got five seconds down, they no longer get a reinforcement for putting them on, they no longer get a reinforcement for five seconds, they now get the reinforcement for wearing them for 10 seconds or whatever, kinda get the idea.

Okay.

Vanessa says, sitting near the toilet in another seat.

Well, that could absolutely be something.

Now that could be a step towards getting closer to the toilet.

So when you think about shaping, that is definitely in the bathroom, it's sitting on a seat.

You wanna think about a behavior that doesn't exist yet, so sitting in a seat does.

And now if you think about sitting on the toilet, what could be used like a first step?

Sit on toilet with the undies on, yeah, that could be it.

That could be how we start.

Absolutely.

What of any other ideas about sitting on the toilet?

The cover down.

Yes, exactly.

Maybe with the cover down, undies on, pants on, maybe the cover down, diaper on, pants on, you know?

Yeah, exactly.

Yeah.

That might be where you start with that and then great, we're doing cover down, let's do cover up.

Awesome.

Let's do diaper off.

Sometimes kids will be okay to sit on it for a second, right?

Second reinforcer, get out of there, and then increase the amount of times.

So that's wonderful.

Now pooping on the toilet is another thing we'll see.

And it's hard to get into all the details of all of this because this is a huge topic.

But if the goal is pooping in the toilet and what will happen a lot, what we'll see a lot in what kids are doing in the moment, instead of pooping on the toilet, is that they're hiding or they're pooping in a closet or behind the couch or off in the corner or in another room.

What we might try to do is figure out, okay, how do we even get them to pooping, like in the bathroom, So maybe what might that look like as a first step?

So they're pooping in their bedroom with their diaper on or whatever, or maybe behind the couch, what might be the first couple of things that we think about if we're starting to work on getting them in the bathroom?

Ooh, a private corner in the bathroom, that's a really great idea.

Yeah.

Any other ideas?

Changing BMs in the bathroom only.

Yeah.

Sometimes that's exactly where we'll start, right?

We'll just start with changing kids in the bathroom.

Yep, in standing, right?

'Cause when you're changing and laying down, that's a whole different thing.

Yeah, exactly.

Maybe even just negotiating with them, like you can still poop in your diaper but you have to do it in the bathroom.

Sometimes that's how we'll start.

So yeah, thanks for sharing.

I really appreciate the engagement.

Okay, we're getting through here.

So prompting.

Again, anybody surprised to see this?

Same sorts of ideas, right?

We might use any of these types of prompting.

And when we really talked about physical prompting, we're often talking about the pieces of like pulling your pants down, pulling your pants up, maybe physically guiding you into the bathroom.

And that, and visuals, again, are another thing that we'll often use to support this process.

There are some visuals you can even get, like where you can see images of the pee or poop in the toilet to make it super duper, duper clear.

And again, like anything, there can be more steps, there can be less steps.

These visuals can be static, they can live in the bathroom.

You can have them in your purse to go to different places, you know, or things like that.

So this is just one example of one way to do it.

What I like about this one is it even has the wiping with it, which is great in the sitting and the standing.

It breaks it down nicely.

Okay.

And practice.

Making time to practice.

And so I have a couple of families, you know, I guess that I'm supporting, and in another way right now.

And what they're really doing is they're like, okay, we're just gonna, like, every evening after bath time we're just gonna, like, practice the routine, like going through the routine, going to the bathroom sitting and one little guy so cute.

His whole thing is right now, he like has the routine down.

He knows.

So like, okay, we get out of the tub.

I grab my footstool and I bring it over, I set it up.

I grab my reducer ring, I put it in.

I get up, I sit down, I finish or not.

We've had a couple of successes recently, that's great.

But then he moves back his stool to in front of the sink, he hangs his reducer ring back up.

He gets up on the stool and washes his hands.

He's got the routine down because they've made it part of the routine, right?

So again, the only thing he's not doing is peeing or pooping in the toilet, although he did just start to pee recently, so that's a little bit exciting.

Having a plan that involves home and school or daycare or whatever is so so helpful if everybody knows what the expectations are and to be on the same page.

And again, allowing the child to do what they can.

And reinforcement.

Who's surprised to hear me saying this?

It is so important, and you know having something ready, limiting access at other times, being creative, sometimes this will even be like, if it's an edible.

And again, I know people don't love to use edibles, sometimes, but it is a really powerful reinforcer.

And What's nice about edibles, you don't have to give the whole chocolate chip cookie, you give a piece of it.

You pop it in their mouth and it's gone.

It's not a toy that you have to get back from them.

It's not an activity that goes on and on and on.

It's it's so easy for it to be immediate.

So for some kids, I will even say like at early stages and depending on the kid, I'll be like, as soon as you hear that pee drop into the toilet, put that chocolate chip cookie in there right away, right?

'Cause you want it to be really, really clear, what it is that you're reinforcing.

So you wanna have something ready, you wanna limit access at other times of this thing.

And again, sometimes you need to be creative, right?

Some kids have limited things that they're interested in.

And again, families, caregivers, schools, teachers, anybody, like there's so many great ideas and creative options out there.

So just try this for me from a minute.

Again, thinking about the positioning piece, 'cause it's so important and it really does matter and make a big difference.

So if you just picture, even just take your feet off the floor right now in the chair.

Like, imagine if you're sitting on a toilet and your feet cannot touch, like, and if you have to poop, you're focusing so much on what, what are you thinking?

What are you trying to do?

You're trying to keep yourself balanced and safe and secure.

Okay.

So what I'm gonna do now.

I mean, we only have seven minutes left, which isn't a ton of time and I know I can be done early.

What I was going to do is a little breakout.

Now what I'm willing to do is if, and the breakup would just be quick.

If there's something you wanna talk about or cover, we can absolutely do that right now and just kinda check in around what the best hopes were.

And if there's any questions or anything, if there isn't, we can do this five minute activity and come back, I'll give you a minute to type some questions in the chat if you have some.

And if not, maybe we won't even do breakout rooms, we'll just do this activity as a group to save time.

But why don't we do that?

We'll do this activity as a group.

If you have questions put them in the chat and after this activity we'll be done.

And in terms of checking in on best hopes, the shoe tying, again, that will come, hopefully the zippering made a little bit more sense.

And I think that was the only thing anybody's shared.

So, we'll do this one as a group.

And then if there's any questions, put them in the chat and we'll go from there and we'll be done.

Okay.

So let's watch this.

(lively music) - To teach your kiddo how to take their shirt off.

First, have them raise one arm, grab the sleeve and then pull the arm down.

Same thing on the other side, arm up, grab the sleeve, arm down.

Then the shirt is ready to take off over the head.

To teach them how to put the shirt on, you wanna hand it to them ready to put on with the tag in the back for them.

Do this by grabbing the neck of the shirt and bunching it up.

With your hands separated so they can put their hands in the middle.

This is what it looks like for them.

Now it's ready to put over the head, one arm up, other arm up, pull the shirt down and voilà.

- [Man] Thank you so much, Meg for teaching us that.

- So what I would like to know from you, the reason I used that activity.

And again, it wasn't specifically related to toileting, it was a really concrete short example of watching somebody do an activity and being able to ask some questions about it.

So my questions about that activity are, what types of prompting was she using there?

Again, just generally thinking that these types of prompting could apply to any of the things we talked about today, what types of prompting did you see?

Modeling.

Yup.

Yup.

Modeling, yeah.

She was using the actual shirt.

What else was she doing for prompting?

Verbal.

Arms up, yep.

That's right.

So there was some modeling, there was some verbal.

Yep, and so if you were thinking about, okay, a task analysis for putting the shirt on, yes, putting the shirt on from what you saw, what would be the steps involved in that?

If you can remember what she did.

As best as you can remember what she did to there.

What might that look like if we were writing it down, writing down the steps for a task analysis?

And it is easier to do that as you're watching of course, but just for the sake of going through the activity.

So the first step.

Neck hole up, tag away from body.

Yep.

So that's exactly right, yep.

Anybody help Joanna with some next steps?

Very difficult to teach bunch up the shirt, or does the adult do that part in hand it bunched up?

That is such a great question, Lindsey, and exactly something that I wonder about too.

And so it can be tricky to teach that, but it is something that we can teach.

Perhaps we use hand over hand to help scrunch it, perhaps we use some modeling to scrunch it, but again, that is one of the steps in the task, right?

So I agree that that would be difficult.

And this isn't the only way to teach this.

This is just for the purposes of looking at it and trying to break down what the steps are, right?

I hope that makes sense, Lindsey.

Sometimes we'll just get the shirt over the head, right?

Arms in the hole.

Yep, thank you, Joanne.

You're right.

And then what was kind of the last step there after the arms were in the hole?

Pull down?

Yeah, so just that activity to highlight, like something simple like that, it's anybody can do a task analysis, right?

And it really just is a matter of either watching somebody else do the activity or you doing it yourself and figuring out the steps.

And sometimes when you do it you might figure out, like Lindsay said, the bunching of the shirt.

If that's something you do, what's another way you could teach that?

What's another way you could do it instead of bunching up the shirt, right?

And thinking about that and putting that step in and thinking about how we teach that.

So I hope that makes sense.

Again, the task of trying to fit this all in a useful way in 90 minutes.

I feel like we got there.

So hopefully you got something helpful from this.

Where to go for more supports or resources?

So if in schools in the HRM and some of the Valley, there's the IWK school therapy.

In other areas, there's occupational therapy, and the services look different everywhere.

There's other specialists in your school who can help you with some of this stuff.

APSEA is an awesome resource for things like this or other information and training.

I forget what the exact name is of.

And I don't know if it's still going, but the like year long autism learning.

I forget what it was called, but the courses that you do on your own time that were so excellent is another really great place to learn lots of tricks.

Do2Learn has great, like, freebies and connectability as well.

So some visuals and things if you wanted to get some of that stuff.

So I didn't see anybody put questions in the chat, and that is kind of where we're at in the presentation.

And we're done aside from that.

So thank you for being engaged.

I know it's tricky when you're looking at...

And sorry, I was looking at my camera some of the times, and some of the times not, I have two screens.

Tricky to be engaged in a virtual presentation like this.

I know, that's why I really appreciate that you were there and I hope you got some nuggets.

- Thank you so much, Victoria.

And we will give a few minutes.

If anyone has any questions, don't hesitate to put those in the chat or use the Q&A.

As I was listening to the presentation, I was thinking, my granddaughter just turned four.

And I was thinking, man, I wish I had had this refresher about a year ago because we just kind of done all these things, except the dressing, I'm definitely gonna use the shirt thing.

But I was chuckling at the comment about the flipping over the coat because my granddaughter goes to daycare and they have taught all of the children.

So they lined them up in the hallway and they all flip.

They stand on their hoods to hold them down first, they put their arms in and they flip them up over their heads.

And it's kind of like a wave going down the hallway when you watch it.

- Do they hit each other?

- They don't actually.

I know, its amazing, I had never seen that before.

So they have it down to a science.

So, early childhood educators are brilliant people.

But thank you so much for that.

And green Skittles for potty training, definitely the way to go.

And I guess the one thing that I was reflecting on as I was listening to this is that these skills are really hard, like they're really hard for kiddos to learn, and they're really hard for adults to teach.

And I know sometimes I've been guilty as a support professional in some of these situations of getting a little bit impatient with folks who are inconsistent or who may not be following through as much as we might like to see, knowing that that's what's really leading to success.

So your points about practicing and allowing the time to practice.

And I loved your comment about, if you're gonna do it anyway, why not just put their hands under your hands and have them have that opportunity to practice.

So lots of really great nuggets that I think will be so helpful.

So thank you so much for taking the time and making the time to share your strategies and your expertise with us, and we really, really appreciate it.

And we have recorded the presentation, so it'll be available on the APSEA website for folks to reference.

Serving Children & Youth Who are Deaf, Hard of Hearing/Blind or Visually Impaired