• Activities of daily living ADL (I)

• Presented by Dr. Shymaa Mahmoud

objectives
➢ Definition
➢ Importance of developing ADL occupations
➢ Factors affecting ADL performance
1- child factors
2- factors around child
➢ Evaluation
1- interviews
2- observation
3- assessment tools
➢ Treatment to improve ADL skills in children
❖ I- Establishing, restoring, and maintaining performance.
Developmental approach
Motor learning approach
Behavioral approach
❖ II-Modifying or adapting the task, method, and/or environment
1-Adapting or modifying task methods
2-Adapting the task object or using assistive technology
3-Adapting the task object or using assistive tools
4-Adapting the work surface
5-Adaptation the task through positioning
6-Adapting environment
❖ Anticipatory approach
Activities of daily living: Self-care or ADLs include
learning how to take care of one’s body, such as
toilet hygiene, bowel and bladder management, bathing and
showering, personal hygiene and grooming,
eating and feeding, dressing and functional mobility.
As the child matures, he can engage in the other
occupations within the family unit and the community such as
education, play, leisure, social participation, instrumental
activities of daily living (I ADLs), and work
Importance of developing ADL occupations

❖Maintaining and improving bodily functions and health (e.g., strength,

endurance, range of motion, coordination, memory, sequencing, body image,
cleanliness in hygiene)

❖ Problem solving while mastering tasks that are meaningful and purposeful to
the child.

❖ Task mastery leads to increased self-esteem, self-reliance

Factors affecting ADL performance:
I- Child factors and performance skills :
• Age, gender, and education.
• Cognitive organization, sequencing, and memory
• Developmental stage, levels of independence, postural control
• Sensory perceptual skills, pain and fatigue.
• Coordination, attention span
• Family’s ability to spend time and be flexible in daily routines
• Ability to learn and generalize activities across environments
 II-Factors around the child
1- Social environment
1- Family members, other caregivers, peers
providing encouragement, support, and decreasing level of supervision.

2- Routines may differ across home, school, community, and recreational

environments. This variation may confuse or disorganize children with
intellectual disabilities, autism or attention deficit disorders but may be
motivating to children without attention, sensory or cognitive problems
 2- Cultural context
- Cultural values influence when children begin dressing,
feeding, bathing, going to bed, and carrying out
household tasks
- The type and availability of tools, equipment, and
materials a child uses to perform ADLs.

-family beliefs, values, attitudes, economic conditions

and opportunities for education and employment
 3- Physical environment
Barriers as:
- Inaccessible buildings
- Rooms crowded with furniture.
- Differences in surfaces
- Sensory aspects of the physical environment
(e.g., the type of lighting, noise level, temperature).
 4- Virtual context
Options for teaching ADLs include videos, computers, televisions

5- activity demands
-vary at clinic, home, school and community
- It involves object used, sequencing, timing, required skills
 Evaluation of activity of daily living
➢ 1. Interviews:
- The child’s/ family goals and dreams, child’s abilities, performance patterns,
habits, daily routines.
- Characteristics of the environment in which the ADL task occurs.
➢ 2. Observation
❖ how well the child performs the task. This includes
- looking at the steps of the activity,
- the sequence of these steps and level of assistance.
❖ Accessibility barriers and the sensory characteristics of the environment
 3. Physical therapy assessment tools
❑ Valid and reliable assessments
a. Functional Independence Measure for Children (Wee FIM)
- is a functional outcome evaluation for children with physical disabilities
- from 6 months–6 years.
- The instrument determines the amount of caregiver assistance needed.
- Three domains are assessed:
- (1) self-care (eating, grooming, bathing, dressing [upper body and lower body], toileting,
bladder management, and bowel management);
- (2) mobility;
- (3) cognitive skills
for a total of 18 items.
b. Assessment of Motor and Process Skills (AMPS)
- assesses the underlying motor and process performance skills used to
perform the task.
- The test has 83 possible tasks, graded easy to hard.
- AMPS is useful for individuals ages 3 year or older and can be used in most
disabilities.
Treatment to improve ADL skills in children:
➢ I- Establishing, restoring, and maintaining performance.
1- Developmental approach:
therapist selects age appropriate tasks through identifying the child’s
developmental and chronologic age and plans treatment according to
a typical developmental sequence.
❖ Therapists often examines underlying body structures and functions
e. g strength

❖ and uses motor control, cognitive orientation, neurodevelopmental therapy

(NDT), sensory integration to restore performance skills.
❖ Example 1:
For children with hemiplegia, constraint induced therapy may establish or
restore movement and use of the weaker upper extremity while the other
extremity is casted.
❖ Example 2:
For toilet training and dressing,
therapists should work to improve the child motor abilities
including postural control, coordination and strength
as well as fine motor skills.
2 - Motor learning approach

❖ learn through practicing the whole task as putting on shoes in a

variety of activities (e.g., dress up, morning dressing routine) or
environments (e.g., home, school, therapy session, gym class).

❖ During practice, the child receives specific feedback (e.g., “pull

the back of the shoe up when pushing the heel down in the
shoe”)
❖ Example:

During toilet training, the training schedule is

directed to improve ability to manage clothes (e.g. take off and put on pants).

For those who use assistive devices or orthotics, they also learn how to
manipulate the devices during toilet or bathing
 3- Behavioral approaches
➢ a- Backward chaining
❖The therapist performs most of the task, and the child
performs the last step of a sequence to receive positive
reinforcement for completing the task.

❖This method is particularly helpful for children with a low

frustration tolerance or poor self-esteem because it gives immediate
success.
❖ Example 1:
During dressing, button all but the first two or three buttons and let the
child button the remaining buttons.
❖ Example 2:
During dressing, pull the zipper half the distance and let the child to complete
zippering
 ➢ b- Forward chaining

❖The child begins with the first step of the task sequence,
then the second step, and continues learning steps of the task in a sequential
order until he or she performs all steps in the task.

❖ It is helpful for children who have difficulty with sequencing and generalizing
activities.

Verbal cues , Physical cues, Gestural cues ,Combination

Picture sequence or checklists
 II-Modifying or adapting the task, method, and/or environment
1-Adapting or modifying task methods
➢ During training on task as dressing in a child with a bilateral upper
extremity amputation, as an adapted method, the child may use the
feet or mouth to write or dress, or may learn new movement
patterns to operate a prosthetic arm (assistive device) for
manipulating objects .
2-Adapting the task object or using assistive technology
❖ It includes talking books ❖ portable memory aids
(e.g., checklists, voice-activated tape recorders)
❖ medication alarm pill boxes,
❖ watches with specialized features (alarms, schedules, talking calendars).
❖ Example 1: During toilet training, developing a
routine for this task through using checklists,
voice-activated tape recorders or alarm for the
day toilet schedules

❖ Example 2:Voice-activated tape recorders

may help the child to recognize sequence and steps for
dressing.
3-Adapting the task object or using assistive tools
❖ Example 1:Various kinds of bath seats are available for providing stable and
safe position during bathing
❖ Example 2: Assistive devices for dressing
4-Adapting the work surface
height, angle of incline, size ,distance from the body ,general accessibility.
❖ Example: For entrance and exits, increase door width, door
rehinged to open in or out or accordion door .
5-Adaptation the task through positioning
➢ The therapist considers positions that maximize independent task
performance.
➢ Adaptive positioning may include using different positions (e.g., sitting instead
of standing), or alternative positions to compensate for physical limitations.
❖ low-technology devices
(e.g., lapboards, pillows, towel rolls),

❖ or high-technology devices
(e.g., customized cushions, wheelchairs, or
orthotics)
6-Adapting the environment
❖ Example 1: modifying the bathroom to make it easier
and safe for the child with disability
Environmental adaptations for the home Bathroom modifications
Structural changes: Including
increased door width;
accordion door,
showers with built-in seat,
change placement of tub
and use closet shelves with no door.
Possible assistive devices: Including safety rails,
single-lever faucets, tub seats, wheelchair shower chair,
angled mirror, wall-fixed hand dryer.
Task modifications: Including liquid soap, soap on
a string, shampoo pump.
❖ Example 2: Modification of bedroom
as using sliding drawers or use shelves instead of dresser drawers for clothes
❖ Example 3: Closet storage system with low shelves
Environmental adaptations for the home Bedroom modifications
Structural changes: Including downstairs bedroom, enlarged closet doors, closet storage
system with shelves, built-in bookshelves at low and medium heights.

Possible assistive devices: Including bed rails, firm mattress, environmental control units or
switches for TV, radio, and light access, enlarged drawer handles or loop added, positioning
devices, adaptive chairs

Task modifications: Including place bed on floor, keep most-used clothes in accessible
drawers, use shelves instead of dresser drawers for clothes, store toys in low shelves
Environmental adaptations for the home Entrances and exits
modifications.
Structural changes: Including hand rails, ramp, stair lift, elevator,
increased door width, door rehinged to open in or out folding door.

Possible assistive devices: Including loop door handle, lever handles.

Task modifications: Including use different entrance, remove inside doors, use
curtains for privacy.
III-Anticipatory problem solving
➢ preventive approach that prepares children and their
families for those unexpected events that may occur
during self-care occupations

➢ Safety measures must be considered to increase the child

confidence and concentration during performance.