Brushing skills in children with special needs: Personal hygiene & activities of daily living

Activities of daily living (ADLs)

As children grow older it is natural to let them take care of their everyday self-care needs. They brush their teeth, bathe and groom themselves with little help from their parents. Introducing your child to self-care early on will ensure they grow to become independent members of the family.  

Consider sensory sensitivities

Children with autism often face difficulties in developing these skills. This may be due to difficulty in motor skills or sensory sensitivity that can be oral hypo or hypersensitivity.

• Hyposensitivity or a low response to stimuli in the oral region can often result in a feeling of numbness or lack of sensation in the mouth. This lack of sensation can often create fear of the brushing process in children, leading to anxiety resulting in children avoiding the activity altogether. 
• Hypersensitivity on the other hand is a heightened response to any stimuli in the oral region leading to overstimulation and an uncomfortable sensation in the mouth.

Why is brushing important?

Brushing is essential for maintaining oral hygiene and for keeping teeth and gums healthy. Regular brushing helps to avoid oral problems like cavities, teeth decay and pain and prevents unwanted oral health issues in children.

When do I start?

Starting early is important as this can help children be desensitized to the sensory stimulation and build a structured routine around the activity. Since this may take a little longer in children with autism, early introduction with a slow and sensitive approach can help master this skill, ensuring health and independence in performing self-care tasks.

How do I start?

• It is important to introduce and start gradually by first understanding the different sensations that the child prefers and those that they avoid. 
• Sensitivity to touch, smell, taste that affect the child should be observed and considered before teaching the skill to the child. 
• Help can be taken from a speech therapist or an occupational therapist who can help identify the sensory sensitivities and also work on any oral motor difficulties that the child might have.
• Selecting the right tools: Ensure that the tools for oral hygiene – toothbrush, toothpaste or tooth powder, tongue-cleaner are selected with the child’s sensitivities in mind.

Toothbrush

1. It is important to select a toothbrush that will suit the child’s sensory preferences. For instance, some children might find the regular toothbrushes hard, in which case a tooth brush with soft bristles can help soothe any unpleasant sensation that the child may experience. Similarly, a child seeking proprioceptive input may enjoy the sensation of vibrations, for which an electric toothbrush can be used.
2. Choosing a suitable toothbrush will help desensitize the child’s gums and teeth and help the child to slowly get used to the sensation of brushing.
3. Furthermore to help the child with difficulties in motor skills, a toothbrush with a broader handle can be used. Alternatively a piece of cloth can be tied on the handle of the toothbrush for a better grip.

Toothpaste or tooth powder

1. Using the same toothpaste as that being used for adults may be counterproductive in children. This is due to the strong smell and taste of the regular toothpaste that can be unpleasant or bitter for children. 
2. There is a wide choice of toothpaste available, which parents can choose from based on their child’s preferences. In case of heightened sensitivities to smell and taste, an unflavoured unscented can also be selected.
3. It is also important to teach the child how to squeeze the tube and apply a small quantity of toothpaste onto their toothbrush.
4. Similarly a toothpowder based on the child’s sensitivities can be selected to make the brushing experience a pleasant one. The child should also be taught how to take the required quantity of powder in their hand.

Adapt to learning styles

Each child is different and they all learn differently. Most children with autism do better when a lengthy task is broken down to simple, sequential steps. 

It helps them understand what is expected in the task, without them feeling overwhelmed. 

• Teaching to Brush in a step by step manner

Breaking down the complete activity of brushing into smaller, sequential steps can be helpful for children as it creates a stress free environment to learn.

1. Position the child in front of a mirror while brushing. This helps the child have a greater understanding of the activity. 
2. Help the child hold the toothbrush independently and apply the toothpaste on it. An order that can be followed while brushing is front teeth, left side, right side and the inner surface. 
3. An effective method to follow can be to use the front to back method while brushing the sides of the teeth and the up to down method while brushing the front teeth. 
4. Once the child learns to brush properly, it is important to teach the child to clean their tongues as well. This helps in eliminating mouth odour and maintains oral hygiene.

• Modelling

An adult can brush their teeth alongside the child and model the activity effectively to the child. This helps the child to learn by imitation.

• Incorporating play

Imaginative play can be incorporated to teach and reinforce children to develop brushing skills. They can be asked to brush the teeth of their dolls or their favourite animals. This can ensure that the children learn this skill, while enjoying a stress free environment.

Provide support

• It is essential for parents and caregivers to understand the different areas of the activity where the child might need added support. 
• They will need to work on these skills in order for the child to learn to brush properly and independently.
• For example: Spitting – Children with autism often have oral motor difficulties, making it difficult to perform actions such as spitting, gargling. Parents can work closely with the speech therapist and occupational therapist to teach the child spitting which can be practiced regularly, while brushing.

Consistency is key

It is important to establish and maintain a consistent routine for brushing. 

• This can be done by picking a time for brushing and maintaining this time every day, as far as possible. 
• The brushing tools like the toothbrush, toothpaste should be placed in the same location, so that the child knows where to find and use them.
• The activity of brushing can further be practiced by incorporating play into it. For instance, the child can be encouraged to role play by ‘brushing’ their doll’s teeth or a set of teeth that the adult can draw on a white board.

Children will learn at their own pace depending on the level of understanding and gradually acquire skills for daily living activities. It is important that we recognize their effort and praise them along the way. This will encourage them to actively participate in the learning process.

Children with Autism are very receptive to learning from visual schedules which serve as a guide that visually illustrates steps of a given activity in a structured manner. Please use visual schedules where possible during the teaching process.

The Jai Vakeel Foundation has helped us compile a step-by-step process to walk your children with special needs through the act of brushing skills every day.

Do you want to teach your child bathing skills as well? Refer to the link here to learn.

You may also seek tips from Ms. Snehal Vaidya, Occupational Therapist about activities of daily living.

If you have questions about Autism, Down Syndrome, ADHD, or other Intellectual Disabilities, or have concerns about developmental delays in a child, the Nayi Disha team is here to help. For any questions or queries, please contact our FREE Helpline at 844-844-8996. You can call or what’s app us.

DISCLAIMER: Please note that this guide is for information purposes only. Please consult a qualified health practitioner for proper guidance.