If you have a kid with autism, especially on the moderate – severe end of the spectrum, you probably have experienced difficulties teaching your child basic personal hygiene.
I believe that the challenge relates to relevance: if something is not relevant, it is difficult for somebody to attend to, and so it is difficult for somebody to learn. My autistic son does not see the purpose of personal hygiene: hair and teeth brushing, washing hands, washing body, putting on deodorant – for him, WHO CARES? It does not matter to him what others see, smell, think. What matters is his own unique sensory experiences.
I think this is not unusual for most boys, but for “normal” boys, at some point in the maturation process, the social implications of poor personal hygiene became undesirable. With my two “normal” guys I had the luxury of hiding my parenting fails behind the passage of time. I don’t have that luxury with my autistic son.
For my son and many autistic individuals, we rely upon rote and routine to teach many tasks. Rote and routine activities are more predictable, comfortable, and comprehensible than new or surprise activities. If you have problems sensory processing, new situations can be too much work. In effect, familiarity makes something relevant. For the caregiver, however, it can be a lot of work to constantly and consistently work the routine, and repeat tasks in step-by-step detail, over and over. Especially when you have other children who need mom’s attention. Fortunately I have had lots of help from the schools. And I have managed to find a few creative motivators of my own to help get a hygiene job done.
I share what worked for us, and a few things that did not work.
- Toilet Hygiene
Some of the textbook personal hygiene techniques that were suggested to me by well-meaning professionals just did not work. As an example, the classic “sink the Cheerios” toilet training technique was a spectacular failure. For N sink-the-Cheerios made no sense. Cheerios? YUM, why not reach in and eat them, with or without pee. This technique of teaching toileting only works if a child understands and enjoys the concept of playing a game and is able to understand that while we eat from bowls, we don’t eat from toilet bowls. Toilet success came after many years of constant repetition and referral to a visual strip showing step-by-step what was expected of him when he had to go. To make things easier, we worked on SITTING on the toilet for both number 1 and 2. We still have visual aids in the bathrooms, to remind him of all the steps, because sometimes he “forgets” to do the steps he does not like, such as wiping or hand washing. Our guests do claim to appreciate the assistance of the graphic autism bathroom decor.
If you have read my previous posts you know that for years we struggled at bathtime. I am happy to report improvement. N still stands in the tub, and refuses to go in the shower. He still stands at the most hard-to-reach location within the tub. He still does not wash himself. But he willingly cooperates. This is a big improvement. I have incorporated bathing into the routine of the evening. N always requests the evening routine by suggesting verbally a possible activity – whatever he might like to do or what comes to mind. I know that means “whats happening next?” My visual now verbal schedule has 2 constants every night: first cook, then bath. If there is an outing, it goes after cook or bath as appropriate. He may not understand why he is getting a bath, but he likes the consistency. I have found a creative motivator: he loves mom’s special attention. He loves it so much that my current challenge is to get him out of the tub when the bath is over. I have to use another creative motivator: to signal the bath is done (and give him reason to exit the tub) I sing a song. It is not my singing that he wishes to stop, it is actually the song itself and its related actions: “A cold wind blows when it is time to get out of the tub,” sung to the tune of “The Beverly Hillbillies” theme song. While I sing it I wave a towel in his general direction, to make a cold wind. As he stands wet in the tub after his bath, if the cold wind keeps up for too long, he gets out.
- Hair Cuts
Because N did not understand the purposes of a haircut, going to the barber initially was an indescribable torture, for him, for his family, and for the barber. He would scream and cry at being caped, restrained for no apparent reason, and for being attacked around his head. Water sprayed and scissors chopped about his face elicited the correct “flight or fight” response. And it was heartbreaking, when we would return to the barber, to reinforce a basically positive outcome, to see the look of abject dismay on the barber’s face. “OH NO…….not THEM…AGAIN?!!!”
We quickly decided this was not a battle we wanted. We tried repeatedly, to adapt N to the haircut. A short term solution was to bring with us, distraction. What worked well were thick, round, slow dissolving lollipops, like the kind you find at Canadian Tire check-out. We found it necessary to bring 2 lollipops, one for each hand, so that there are no hands available to engage in self-defence. Also, instructions to the barber that speed was more important than quality did help alleviate barber stress. Eventually we decided to adapt the haircut to N. We brought the process in house. I had watched those barbers very carefully before purchasing a men’s grooming kit. Now all my boys are cut at home. They all get buzz cuts. I no longer use a visual schedule: I place a chair in the middle of the bathroom and I announce to all – “barber shop is open!” N knows that hair cuts are coming. N can see his brothers also being attacked around the head. He sees that they are unafraid and unharmed. We praise N for his cut and I make sure he gets lots of “Moms Special Attention”.
Something that smells great can be (a) rubbed in your arm pits; (b) eaten. Our issue was that N correctly chose (b). My dad is in Long Term Care, and I remember him telling me that one morning after a visit from N and I, his caregiver who was preparing him for the day remarked “Brian, your Speedstick has teeth marks in it!”.
We have not been terribly successful in dealing effectively with the issue of eating things that smell good but are not edible. So, we decided to teach him to use unscented roll-on. And we have a very simple visual schedule for the morning routine consisting of 5 pictures: “get dressed”, “breakfast”, “armpits”, “teeth”, and ” school bus”. Each morning I verbally prompt him “do your pits” while I am doing mine. He has his easily accessible “Dry Idea” unscented roll on (The rest of the family have their preferred deodorant carefully hidden somewhere to avoid being consumed). Although he does not really understand why he rubs that stuff in his armpits, he cooperates, because it is routine and familiar.
Like hair cutting, nail cutting was viewed by N as a kind of attack that elicited primitive self-defense mechanisms. What I found worked best were large nail clippers, as opposed to small clippers or nail scissors. Toenails were always easier, as long as the hands could be occupied with something to provide visual stimulation. Hands were a bigger challenge, and they were also always the priority, as those nails did plenty of scratching. I had to find a sufficiently interesting VISUAL distraction, for one hand. I was fortunate, N had no hand preferences, which made it possible to cut nails on both hands.
Now that he has had his nails cut so many times, he is cooperative, and comfortable, with the routine.
- Hair Brushing
Both N and the dog will run if they see me coming toward them with a brush in hand. For N, who dislikes the sensation of the brush, the obvious solution was to cut his hair short enough so that brushing was not necessary. Forget routine and rote learning, I need to pick my battles. The buzz cut – truly, a wonderful thing! For the dog however, we are still trying to figure out how to best get her looking her best.
Will rote and repetition tempered by creativity eventually result in independence? I am cautiously optimistic, but the road ahead is long and the obstacles are ever changing. Tune in later for an update on tooth brushing, dentist disasters and facial hair shaving.