Module 3 : Fine motor skills and toileting

[vc_row][vc_column][vc_single_image source=”featured_image” img_size=”large” alignment=”center”][vc_column_text]Many intricate fine motor skills are needed for toileting. From doorknobs, clothing fasteners, tearing toilet paper and turning on water taps; there is a lot for little hands to handle. children need to demonstrate proficiency in several areas of fine motor functioning in order to be independent with toileting.

If you have hand weakness or other fine motor problems, you may find it difficult to pull your pants up and down, fasten your pants, and wipe yourself afterwards. This may be an area of difficulty when it comes to toileting. 

Therapists love to use something called task analysis when working with children (and adults) on functional skills of daily living. Task analysis is a means of breaking down every step involved in completing an activity from the very beginning to the very end. It is a great way of looking more closely at the fine motor requirements of toileting.

Fine Motor Skills Needed for Toileting

Going to the bathroom entails more steps than what most people realise. Below is a list that may help you understand all the fine motor skills needed to successfully go to the toilet:

1. Open the door/stall to the bathroom
2. Lock the door/stall
3. Unbutton/unsnap/unzip pants and unbuckle belt
4. Pull pants and underwear down
5. Retrieve toilet paper
6. Wipe/dispose of toilet paper
7. Pull pants/underwear up
8. Snap/button/zip pants and buckle belt
9. Flush toilet
10. Unlock stall
11. Turn on water
12. Get soap from container
13. Rub hands under running water
14. Get paper towel/towel to dry hands

children need to demonstrate proficiency in several areas of fine motor functioning in order to be independent with toileting:

Grasping and manipulation skills

These skills are necessary for completing clothing fasteners, retrieving toilet paper and paper towels, using a tap, opening and closing doors, locking and unlocking doors, and pulling pants up and down.

Hand strength

Hand strength is necessary in order to exert enough force to push the pump on a soap container, to pull pants up and down, to complete fasteners, to flush the toilet, and to retrieve paper towels.

Bilateral coordination

Bilateral coordination (which is the ability to use both sides of the body together at the same time in a controlled and organised manner) is needed for managing clothing fasteners, washing hands, and drying hands.

Fine Motor Skill Deficits and Toileting

A very common reason for occupational therapy referrals is difficulty with independence in the bathroom. When fine motor deficits impact a child’s independence in the bathroom, there may be social repercussions as well. They may be more likely to have accidents at school, which can make them stand out from their peers. Children who need to ask for help with clothing fasteners and clothing management may become too embarrassed to use the bathroom at school or to go to sleepovers.

When children are unable to complete dressing tasks, clothing fasteners, and other parts of the bathroom routine due to these deficits, it can impact their ability to make it to the toilet in time to prevent accidents. This plays a major role in toileting, especially for beginners, as timing is everything. 

Being able to undress independently is one skill to look for as a sign of readiness for potty training.

Fine Motor Activity Suggestions to Help with Toileting

Some traditional activities that can address the underlying fine motor needs related to toileting include:

• Practicing with clothing fasteners
• Hand strengthening activities
• Practicing dressing skills
• Grasping activities
• In-hand manipulation activities
• Practicing the motions needed for wiping

GRASPING SKILLS

The term “grasp” is easy enough to understand. It is simply a description of how children pick up and hold onto anything in their environment. However, there are a huge variety of different grasp patterns kids use every single day as they play, work, eat, dress themselves, etc.

These grasp patterns tend to change and progress as children grow from infants into toddlers, pre-schoolers, and eventually big kids.

Most children will naturally progress through the developmental grasp patterns without difficulty. Exposure to play opportunities that allow children to develop their grasp strength and coordination can ensure that they’ll be prepared with the skills they need to be successful with grasping activities that may be required in the toileting process. Some examples are opening and closing doors, turning on and off the water, turning on and off the light and managing clothing.

Here are great, easy and fun activities do develop hand strength:

• Clips and clothespins are great for developing strength in the muscles needed for a good tripod grasp. A tripod grasp is the thumb, index and middle finger holding the item.
• Cooking with children is a fun way to promote good grasping skills by practicing the use of cooking tools and utensils.
• Tongs are great for helping children develop the “precision” side of their hand (the thumb, index finger, and middle finger) for grasping.
• Lego or Duplo blocks – These are both great for developing grasp strength. Smaller Lego bricks are great for older children with more advanced skills, while the larger Duplo version is best for the younger crowd.
• Stickers or Tape – Pulling tape and stickers from a roll and/or pulling them off various surfaces (walls, tables, and floors) is a great hand strengthener for children

MANIPULATION

In-hand manipulation skills allow children to explore and use small objects and are integral for some of the tasks involved in toileting. There are three primary in-hand manipulation skills: rotation, shift, and translation. children use translation and shift to retrieve and manipulate toilet paper and to complete clothing fasteners during the toileting process.

children typically develop in-hand manipulation skills between the ages of 2 and 4, with finger to palm translation developing first, followed by palm to finger translation, rotation, and shift.

At these young ages, children are able to perform the skills with a single object. By ages 6 to 7, they are able to manipulate and stabilize multiple small objects within the hand and can use these in-hand manipulation skills more purposefully and functionally.

These activity ideas can promote in-hand manipulation skills:

• Make crafts with small pieces/objects.
• Play games with small pieces and manipulatives. 
• Put coins into a piggy bank or small objects into a container with a slit cut in the top.
• Practice opening and closing containers with tops that twist on and off.
• Play with spinning tops and wind-up toys.
• Practice stringing beads.
• Crumple and/or tear paper.

HAND STRENGTH

Children need strong hands to manage their toileting environment. They will need to handle the doors and faucets, rip and manage toilet paper, and flush the toilet as well as button, snap and zip.

When it comes to toileting, these are the red flags that are related to clothing management that you might notice if a child has weak hands:

• Inability to grasp and pull the waistband of pants up and down over hips
• Difficulty with maintaining grasp on a button to pull it through a buttonhole
• Zippers coming disconnected mid-zip because the two sides aren’t being held together tightly
• Inability to snap/unsnap pants, sometimes resulting in toileting accidents
• Inability to pull with enough force to fasten or loosen a belt buckle
• Inability to open the doors

The good news is that there are tons of fun and playful ways that can help children build hand strength in the classroom, in the therapy room, and at home. Think of activities that fall into one of these three categories: weight-bearing activities, pushing and pulling activities, and squeezing activities. 

Here are a few examples to get you started:

WEIGHT BEARING ACTIVITIES FOR CHILDREN

Try the following weight bearing activities to strengthen the hand while building stability in the proximal arms/shoulder girdle.

• Crawling – Try relay races, obstacle courses, and other games.
• Donkey kicks – Have the child bend forward to place their hands on the floor and then kick with their legs up and behind like a donkey.
• Wheelbarrow walks – Have the child place their hands on the floor while you or another child holds their hips. See how far they can walk on their hands.
• Play on all fours – Try playing board games, colouring, or playing with toys in a crawling position so the child is holding their weight on their hands.
• Play while lying on stomach – build puzzles or play with blocks while lying on your stomach. 

PUSHING AND PULLING TOYS AND ACTIVITIES FOR KIDS

Try some of the following pushing and pulling activities to strengthen the hands.

• Velcro – Pulling against heavy-duty Velcro is another great hand strengthener. Try adapting books using Velcro, making file folder games, or making other fun Velcro fine motor tasks.
• Connecting Beads – Large beads that pop together are great for strengthening the larger muscles of the hand and the smaller version is great for developing the precision (or smaller) muscles.
• Rubber Bands – children can stretch and pull against the resistance to create masterpieces on a geoboard or try other fun rubber band fine motor activities.
• Rolling Pins – Grasping, pushing, and rolling with rolling pins are great ways to strengthen little hands and fingers. Try it on play dough, bubble wrap, or during cooking activities.
• Thera-band – This stretchy stuff is another great “tug of war tool.” There are all kinds of ways to pull on it and against it to strengthen hands – children love doing this. 
• Thera-putty – This is a great tool that children love that helps to develop hand strength. You can roll, clump together, pull to stretch and do many more activities with this amazing material. 

SQUEEZING ACTIVITIES FOR KIDS

Try some of the following squeezing activities to strengthen the muscles in the hands.

• Playing with play dough, putty, or clay – Squishing, pinching, rolling, squeezing, mushing – all great for building muscles in the hands.
• Sponges – Get children involved in chores where they have to wring out sponges or wet rags. A clean house and strong hands? Sounds good to me!
• Spray bottles, water guns, or squeeze bottles – Have a water fight in the backyard or have children water your plants with a spray bottle.
• Squeeze balls or stretchy balls – Use these as fidget toys or challenge children to do several repetitions of squeezing or pulling to build strength.
• Hole punches – These little hand strengtheners come in all shapes and sizes – great for making hole punch crafts with children. 
• Curvy cut scissors and clay – using curvy cut scissors to cut out shapes of clay is a great hand strengthener. 

BILATERAL COORDINATION

The final piece in the fine motor puzzle for toileting is bilateral coordination. This is the child’s ability to use both sides of the body at the same time to complete a movement or task. This is how a child manages to do tasks like buttoning their pants, stabilizing and tearing toilet paper, or stabilizing the bottle of soap as they pump it into their hand. Some ideas to get a child practicing bilateral coordination might include:

• Using scissors – Encourage the child to hold the piece of paper while they cut.
• Climbing on playground equipment – Encourage the child to work on crossing the monkey bars, climbing up and down the ladder, and up the slide.
• Playing tug of war – Have child play a game of tug of war or use a rope to have child pull something to themselves hand-over-hand.
• Using a pool noodle – Have child swing a pool noodle with both hands to try to hit a balloon.
• Tearing paper – Have child tear paper to create an art piece or simply tear paper in the recycle bin.

When all these foundational fine motor skills are in place, children are ready to work on another complex aspect of toileting – completing clothing fasteners. Without independence in this area, children are more likely to have an accident or become frustrated by the toileting process.

Tips for Teaching Kids to Zip and Button Clothing

1. Start Early

It’s never too early to expose babies and young children to fine motor toys and play activities. Toys with buttons to push, handles to grasp, or moving parts to manipulate are all fantastic options. Encourage the efficient use of both hands together in babies and toddlers by introducing shape sorters, puzzles, and any “put in” activity (children LOVE filling up containers with almost anything you can find around the house).

2. Pre-Fastener Activities

For younger children, get started by presenting some “pre-fastener” activities that work on manipulation skills and get both hands working together efficiently. Some examples might be: stringing beads, lacing cards, pushing pick up sticks or toothpicks into Styrofoam or clay, or playing with buttons by gluing them onto a frame, sorting them by colour or size, stacking them, etc.

3. Beginning Fastener Activities

Next, move on and start to practice with activities that are closer to the real thing.

• Put loose buttons or coins into a container with a slit cut in the top (an empty ice cream or yogurt container is perfect).
• Use a button snake to get little hands practicing with real buttons.
• Pass loose buttons through buttonholes on real clothing that is not on the body.
• Practice hooking zippers and fastening buttons on clothing that is not on the body to make it easier to see and manipulate.

4. The Real Thing

Now, kids will be ready to practice with clothing that is on their bodies.

• Start with the largest buttons and zippers you can find.
• Provide lots of repeated hand over hand practice for zippers. This helps children feel and visualize how to hook the two sides together.
• Add a ribbon or string loop to zippers on children’s coats and sweatshirts to make a larger zipper pull.

The most important thing is patience. Trying to practice these tasks when you’re in a rush or when the child is urgently trying to use the bathroom is NOT the time! Challenge children to be more independent but take it one step at a time.

Strategies and Modifications to Support Fine Motor Skills for Toileting

During the actual task of toileting, children will need all of the fine motor skills described previously.  There are some strategies and modifications that can help to support independence with the fine motor requirements of this task.

1. Strategies:

Practicing the motions or motor skills needed for wiping can be helpful for some children. There are several strategies and activities that can simulate this action while strengthening the skills needed for independence in the bathroom. Here are some strategies that may help your child:

• Practice washing their backside in the tub.
• Put a handkerchief or scarf in the back pocket for the child to reach for and pull out.
• Put stickers to the back of the child’s pants for the child to reach for and pull off.
• Put plastic over the child’s pants and then apply something sticky on the plastic that they have to practice wiping off. This way they can practice the movements needed in a safe way.

2. Modifications and Adaptations:

For some children with significant fine motor impairments, modifications are needed for the fine motor tasks involved in toileting.

• Use a modified position to provide stability – allowing the child to complete clothing management in a sitting position, lying down, or leaning on the wall for support
• Wearing larger-sized pants can make it easier for the child to pull them up and down independently.
• Wearing pants with elastic waistbands can make it easier for the child to manage and eliminates the need to complete fasteners.
• Replace buttons and snaps with Velcro or magnetic fasteners.
• Use a button hook and/or zipper pull to help with button fasteners and zippers.
• Add longer zipper pulls or a ring to zipper fasteners.
• Use toilet aids to assist with wiping.
• Use wet wipes for wiping.
• Use a consistent approach with a predictable routine.
• Use picture cues to help the child learn and understand each step of the process.
• Place loops on the waistband of pants.
• Modify buttons and snaps.

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