Activities of daily living

18


Activities of daily living


MICHELLE DESJARDINS and JULIE SAVOYSKI



Chapter objectives


After studying this chapter, the reader will be able to accomplish the following:


• Describe the progression of activities of daily living (ADLs)


• Describe a collaborative approach to help children develop the ability to engage in ADLs


• Develop intervention strategies to improve engagement in ADLs in children and youth


• Understand the concept of co-occupation as it relates to designing and implementing intervention for ADLs


• Describe remediation, compensatory, and adaptive strategies to help children perform ADLs


• Identify adaptive equipment and devices that help children perform ADLs



Key terms




CASE Study


Ashley, a 10-year-old girl, and her family were returning home after visiting family members out of town during school vacation. Her family’s car was struck by an oncoming vehicle, ejecting her through the front windshield from the passenger seat. Emergency personnel immediately transported Ashley by ambulance to a local hospital, where she was assessed and transferred via helicopter to a large pediatric acute care hospital. During her hospital stay, Ashley’s medical team determined that she had sustained a traumatic brain injury (TBI) and an incomplete C6-C7 spinal cord injury (SCI). After multiple diagnostics, surgeries, and daily skilled inpatient rehabilitation, Ashley was discharged to a local pediatric unit within an acute rehabilitation facility.


After completing your new employee orientation and training period, today is your first day treating a full caseload as an occupational therapy assistant (OTA). The supervising occupational therapist gives you Ashley’s chart to review and reminds you that she is first on your schedule. Her parents drove in early this morning to observe your occupational therapy (OT) session. They are concerned about Ashley’s self-care abilities. What is your plan?



This chapter addresses activities of daily living (ADLs) in children and youth. Specifically, in accordance with the Occupational Therapy Practice Framework: Domain and Process, 2nd Edition, ADLs, an area of occupational performance, will be addressed in reference to the pediatric population. ADLs comprise meaningful activities that encompass self-care: bathing and showering, bowel and bladder management, dressing, eating, feeding, functional mobility, personal device care, personal hygiene and grooming, sexual activity, sleep/rest, and toilet hygiene.2 This chapter addresses developing the OT intervention plan, implementing therapy, measuring progress, and planning for discharge. Specific intervention strategies and case examples are provided throughout to promote learning.




Pediatric occupational therapy and ADLS: a collaborative approach


OT practitioners working in pediatrics are faced with a diverse caseload of clients with complex medical and developmental issues. Infants, children, and adolescents may present with multiple diagnoses and symptoms related to conditions that influence their overall level of functional independence in occupational performance. OT practitioners address individuals’ holistically, regardless of age, disease, or disability and therefore individualize the intervention plan to meet the unique needs of each child and his or her family.


Regardless of the setting (e.g., acute care, community, school), disruption or interference with the process of development affects not only the pediatric client but also family members, caregivers, and friends within the client’s physical and social environments. Client-centered and family-centered approaches are integral to the OT process, and meaningful activities should complement cultural values and beliefs.6 Viewing the client holistically, as an occupational being who has individual habits, roles, and routines is considered part of the dynamic OT process.11


OT practitioners working with infants, children, and adolescents have the opportunity to facilitate skill acquisition so that children and adolescents can engage in a variety of ADLs. As development typically occurs in a sequential pattern, OT practitioners working with children and adolescents are challenged to think “outside the box” to determine how internal (e.g., motivation, cognition, emotions, muscle tone) and external (e.g., cultural, physical, environmental) variables interfere with development. For example, a child diagnosed with a congenital anomaly, acquired disability, or developmental disorder may present with symptoms that interfere with the maturation of functional skills. The child’s condition or symptoms may interfere with his or her ability to learn both basic and higher-level skills, which may result in deficits in functional skill development and transfer of learning across multiple contexts.20


Pervasive developmental disorder, congenital anomalies, developmental delays, rare genetic disorders, acquired disabilities, and psychological conditions are examples of diagnoses seen by the OT practitioner who works with children and adolescents. Regardless of the symptoms related to the client’s diagnosis, the OT practitioner views the individual as an occupational being who needs “to be able or enabled to engage in occupations.”23 OT practitioners working in pediatrics must possess knowledge of the theory and principles of intervention and understand the dynamics of the child and the family. Understanding their life stories and their expectations for future occupational participation is integral to the OT process.


As the OT process unfolds, analysis of occupational performance guides practice. The OT practitioner provides the groundwork for intervention by collaborating with the OTA, the child, and the family. Using a collaborative team approach enhances occupational performance outcomes (e.g., independence in ADLs). Under the direct supervision of the occupational therapist, the OTA may be responsible for assisting with goal development, selection of intervention approaches, determination of the means of service delivery, and selection of outcome measurements within the intervention planning process, depending on his or her level of service competence. Once the initial intervention plan begins to be implemented, OT practitioners are responsible for establishing therapeutic rapport, incorporating meaningful activities into treatment, consulting with various professionals, and providing education to the client, family, facility, and community.



A developmental perspective of ADLS


Infants and toddlers rely on others to ensure that their basic needs are met. As they grow older, they begin to engage in self-care tasks such as bathing, feeding, dressing, and bowel and bladder control. They begin to move around the environment (to explore their surroundings) and sleep or rest. They learn to tolerate sensations, listen to body cues, and use their hands to manipulate objects. Infants born with congenital anomalies or inherited disorders and those born prematurely may experience difficulty tolerating, managing, and learning the skills needed to perform ADLs.


Infants, toddlers, and adolescents have many opportunities to engage in ADLs in natural settings and across multiple contexts (e.g., home, daycare, community). Peers and siblings often demonstrate how to initiate, sequence, and complete ADL tasks. Parents and teachers play essential roles in teaching children how to engage in ADLs.


Adolescents and teens experience internal variables (e.g., emotions, self-concept, motivation, initiation) and external variables (e.g., peer pressure, social expectations) that influence ADL performance. Social attention, peer pressure, body image, and sexuality influence occupational performance in activities such as hygiene, dressing, and sexual activity.



Co-occupation


The term co-occupations refers to occupations shared by at least two individuals.14,24 A naturally occurring co-occupation involves a parent calming his or her child. In this case, the child is responding to the parent (social participation), and the parent is engaging in the caregiving role. Infants rely on others (such as caregivers, parents) to provide sensory stimulation, opportunities to develop relationships, and exposure to sensorimotor opportunities for skill acquisition. OT practitioners address deficits in co-occupational performance and consider the complexities of relationships when developing interventions for ADLs.14,24


OT practitioners work with children who come from diverse environments and cultures, including children who have been adopted from orphanages outside the United States. Exploration of the environment in early childhood is essential for optimal sensory and motor development. Many children deprived of early sensory experiences (such as those in orphanages) experience long-lasting sensory (such as vision and touch processing) and motor difficulties.3,12 Children from orphanages who are institutionalized for prolonged periods may exhibit motor planning, sensory discrimination, and sensory modulation issues.12 Working collaboratively to support the co-occupations of families is helpful to children and may promote the development of ADL skills.24



Evaluation to intervention


The OT practitioner completes an occupational profile to better understand a child’s strengths and weaknesses and develop functional goals addressing occupational performance deficits. The occupational profile provides an overall picture of the child’s functioning, including contraindications, signs and symptoms, and performance skills. The OT practitioner considers the child’s family, culture, and environment while planning the intervention.


The following guidelines may help practitioners design various interventions to address ADLs (Box 18-1).



BOX 18-1   Guidelines to Design Interventions to Address ADL Performance




• Review the occupational profile, including goals and recommendations.


• Ensure all contraindications are taken into consideration during intervention planning and implementation.


• Be comfortable explaining the role of an OTA (in nontechnical terms) to the client and/or the family.


• Use universal precautions during interventions.


• Address the performance deficits and environmental modifications that enable children to be successful in participating in occupations such as ADLs.


• Encourage active client participation, and involve caregivers.


• Remember that the pediatric OT process is a dynamic one and that alterations to the intervention plan may be indicated over time.


• Consult with the supervising occupational therapist, the client, and the team (including family, caregiver, and staff members) throughout the OT process regarding goals and progress.


• Document progress clearly.


• Report any concerns about the intervention process to the supervising occupational therapist.


• Utilize available professional resources for assistance.


• Collaborate with all team members during discharge planning to ensure that the consistency of care will continue.



Intervention strategies for the pediatric occupational therapy practitioner


Bathing and showering


Bathing and showering are occupations that comprise multiple tasks and sequences, including “obtaining and using supplies; soaping, rinsing, and drying body parts; maintaining bathing position; and transferring to and from bathing positions.”2 Infants and toddlers are at the beginning stages of concept development in that they are just learning the purposes and functions of objects and activities. They have not yet ascribed meaningfulness to the act of being bathed. For infants and toddlers, bath time provides an opportunity to play and enjoy the sensations while making sense of objects. Bath time may also be a fun time for those with special needs to work on performance deficits (e.g., range of motion [ROM], stretching, positioning). Some adolescents view bathing and showering as a meaningful self-care activity that ensures health. For teens, bath time provides the OT practitioner and caregiver(s) the opportunity to work on remediating or compensating for performance skill deficits.


Children and adolescents may have difficulties with bathing and showering for many different reasons (e.g., motor, sensory, cognitive, behavioral, developmental). The OT practitioner begins with an analysis of the client’s strengths and areas for growth (obtained from the occupational profile) to determine the best intervention. The following examples illustrate intervention strategies for bathing and showering.



CASE Study


Molly, a 3-year-old toddler, is referred to pediatric OT following a right proximal humerus fracture with no medical precautions. Areas for growth, identified from the occupational profile, include right upper extremity active ROM and strength, independence in self-care, and endurance during functional play tasks involving right upper extremity use. Molly’s mother is worried about bathing her as she is hesitant to hold her and move her right arm.


What is your intervention plan? Develop a list of at least three therapeutic activities for the OT session. List four recommendations for Molly’s mother addressing both therapeutic handling and safety.



With children such as Molly who are in need of remediation techniques for motor or praxis skill deficits, the focus is on meeting the client where he or she is currently functioning, facilitating the return to previous functional status, and improving overall independence. Remediation techniques include upper extremity therapeutic exercises (ROM and strengthening) and therapeutic activities to increase active participation and independence. Grading the location of bath supplies on shelves by altering the shelf height or the placement of supplies on the shelves will provide the child with reaching opportunities prior to entering the bath tub or shower area. Use of warm water creates a therapeutic environment for exercises. Some children may perceive showering or bathing as a calming, leisure-based occupation.


OT practitioners may incorporate functional activities, for example, they may have the child reach above shoulder height to retrieve their favorite toys, while physically supporting them in the bath tub as needed. Games such as various-sized water toys, weight, and resistance support the child’s intrinsic motivation for play while improving bathing and showering skills. Involving the caregiver in the session helps with carryover or incorporating the OT strategies into the child’s daily routines and also serves as an intervention strategy. Educating the caregiver on positioning, handling techniques, and overall safety is essential.


Children presenting with neurologic, sensory–perceptual, emotional regulation, and cognitive deficits may have difficulty with aspects of bathing and showering and require remediation. They may benefit from intervention techniques to improve motor performance to complete ADL activities guided by control or motor learning, neurodevelopmental therapy, sensory integration, or developmental frames of reference. For example, preparatory activities for a client with low muscle tone include stimulatory activities such as vibration, whereas calming tasks such as rocking are indicated for clients with spasticity.17 Cold increases muscle tone, and neutral warmth relaxes muscle tone. These basic concepts are important as the activity demands of bathing and showering call for the ability to retrieve, manipulate, and use various supplies; maintain body position (i.e. standing up against gravity with water resistance or bathing in supine moving within the water); transfer between positions; and washing and drying self.2


Cognitive skill remediation includes analyzing tasks into small steps via forward or backward chaining (Table 18-1).16 The OT practitioner facilitates the process by having the child or adolescent initiate the first step of a sequence or complete the last step of a sequence, depending on the chosen intervention approach. The OT practitioner continues to gradually increase the level of difficulty over time. The multicontextual frame of reference emphasizes learning skills and transferring skills to the natural context.20




CASE Study


A 14-year-old adolescent, who has been diagnosed with schizophrenia and major depression, presents with flat affect, decreased socialization skills, and lack of motivation to complete daily grooming tasks prior to school. On the basis of the information obtained while completing the occupational profile, the OTA plans and implements a sensory inventory to gain more information about the child’s sensory preferences for intervention. The adolescent reports a strong preference for warm sensations. The OTA, the adolescent, and the mother work together, coming up with a strategy to increase the adolescent’s motivation and frequency for showering. The collaborative decision to have the adolescent’s mother turn on the shower 2 minutes before wake-up time, paired with the verbal cue “Your warm shower is ready,” helps the adolescent tolerate the shower three times during the first week. The adolescent’s motivation to engage in bathing and showering is facilitated by the intrinsic motivation for experiencing sensations involving warmth and hearing her supportive mother’s voice. The adolescent and the mother both report a sense of progress in accomplishing ADLs—a true example of successful co-occupational performance.



In addition to remediation, OT intervention may include compensatory techniques. For example, children with deficits that interfere with ADL performance (such as congenital anomalies resulting in delayed growth) may benefit from the following:



• Self-care training using assistive devices or adapted techniques, including long-handled self-care supplies (i.e., sponge), shower chairs, reachers, nonslip tub mats, safety bars, and/or removable shower heads


• Staff supervision and implementation of a visual schedule for an adolescent with cognitive skill deficits residing in a group home setting, which is another possibility for support during occupational participation


• Labeling items in large print and contrasting colors to support pediatric clients with low vision


• Incorporating adaptive techniques such as using a container with one U-shaped side to rest against the client’s head for washing hair to eliminate the need to tilt the head backward, which may cause distress.


• Ensuring a smooth transition from a bath or shower with a snug towel wrap to help the client handle increased sensitivity to change in temperatures and to provide the sensory supports to maintain an optimal level of arousal


• Education to parents, caregivers, and staff members on the level of supervision needed throughout bathing and showering as necessary


• Rearrangement of a client’s bathroom to accommodate a wheelchair and/or shower chair as necessary


• Education on work simplification or energy conservation to support co-occupation and prevent caregiver “burnout,” especially when the child’s needs are complex and physically taxing for the caregiver


Assistive technology may help children succeed in performing ADLs. Computer-simulated programs for self-care tasks may assist the children in learning the required sequences for bathing and showering prior to attempting the multistep task in the natural context. Using the computer for organizational purposes may be beneficial as well. Having a concrete visual schedule that includes the day and time for bathing and showering is an additional means of cognitive support.


Multiple modes of functional communication may promote self-advocacy in the child or adolescent. For example, a young child who is nonverbal may use an alternative augmentative communication (AAC) device. The OT practitioner facilitates self-advocacy by ensuring that the means of communication is readily available and accessible at all times.18 A voice output device may allow children with neurologic conditions such as cerebral palsy to express preferences for occupations, including activities throughout the bathing and showering process, that do not compromise breathing.



Bowel and bladder management


Bowel and bladder management encompasses both the voluntary control of bowel and bladder movements as well as the utilization of alternative methods, including the use of equipment, to support bladder control.2,21 In order to optimally manage bowel and bladder functions, which include processes of both volition and intention, an intact neurologic system is essential.9


Infants and toddlers begin developing the concept of bowel and bladder functions in addition to processing sensations before developing motor control abilities for the volitional control of their actions. As with all development, some children will mature in this domain at an earlier stage of life than will others. Young children, through either structured or nonstructured programming, have environmental affordances such as education, caregiver assistance, peer-modeling opportunities, and physical setup to support the development of functional skills. During the school-age years, children develop and participate in a consistent routine. Continued adaptations are made in accordance with daily scheduled activities throughout adolescence and the teenage years.



CASE Study


Destiny, an 11-year-old child, attends a private day school for children with complex needs, including behavioral and sensory issues. According to her occupational profile and individualized education program (IEP), Destiny’s primary medical and educational diagnoses are visual impairment, hearing impairment, and autism. She relies primarily on her tactile, proprioceptive, and vestibular sensory systems for information regarding where she is physically in space as well as in proximity to other persons and objects within her physical environment. In addition to OT, she receives speech and language therapy and physical therapy services. Destiny also works with a certified orientation and mobility specialist, who teaches those with visual impairment and has advanced training in teaching those with hearing impairments

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Related posts:

  1. Scope of practice
  2. Applying the model of human occupation* to pediatric practice
  3. Development of occupations
  4. Functional task at school: handwriting

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Jul 24, 2016 | Posted by in PEDIATRICS | Comments Off on Activities of daily living

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