Bathing

Bath and Shower time can be a fun time for some children but for others it can be overwhelming. For example, a child with postural or motor planning difficulties may feel unsecure sitting and moving around the bathtub and be anxious about falling or slipping when it is time to have a bath or shower or a child who is particularly sensitive to sensory input may not like the feel or sound of the water running, the smell of the bubble bath or the feel of the soap on their skin. The result of the above sensory processing difficulties is that the child may be reluctant to bath or shower and this can be stressful for the whole family.

To learn more about whether you child is under or over responsive to sensory input, you could ask yourself some questions about what you observe of their behaviour.

Touch

Does your child dislike taking clothes off, water, soap, bubbles, hair washing or towel?

Does your child dislike change in temperature from other rooms in the house?

Now try these practical suggestions:

• A massage beforehand can help your child prepare for bathing or showering - Always touch on the child’s terms. Ensure they are as calm as possible and ready to accept touch. A firm pressure massage can help the child to feel calm and more able to cope with sensations.
• Ensure the bathroom temperature is comfortable. Do they like to be warm and cosy or do they prefer a cooler room.
• For hair washing try rinsing their hair using a sports bottle or cover their eyes using a cloth or hair washing shield. Hair washing shields are available from various shops.
• Encourage them to wash themselves so they are in control of any touch input. Demonstrate and give some instructions on how to move body parts and what you need to do to get washed, then encourage them to do as much as they can for themselves. This will not only promote independence but will also give them control. It will reduce the change of them being touched unexpectedly which can feel uncomfortable.
• Use a firm sponge to decrease sensitivities. Using lighter or more gentle things to wash with may feel tickly.
• Use firm pressure when assisting with washing whether this is with a sponge/cloth or just with hands. Firm pressure can have a calming effect, and the child may actually enjoy this sensation. Firm pressure can reduce sensitivities and therefore splashing water, skin being touched, head being touched, and the sensation of soapy skin may easier for the child to tolerate.
• In the shower allow the child to use a handheld nozzle so they are in control. Handheld nozzle’s that attach to bath taps are also available from various retailers and sometimes in the bath a child may prefer to rinse using this.
• After a bath or shower quickly wrap your child in a warm towel. Once dried, a firm massage using body lotion can help prepare for bedtime. As previously mentioned, temperature can affect a child’s ability to cope with bath or shower time. Having a cosy towel ready as soon as they get out will help them to feel comfortable. Deep pressure again can help at this stage so wrapping the towel tightly round the child may be good. If the child is still feeling uncomfortable with all of the sensory experiences they have been exposed to during bathing or showering, it may help to give them a massage after to help reduce discomfort and to help with calming before bed.

Smell

Can your child feel uncomfortable with different smells? What appears pleasant to you may be unpleasant and difficult for your child to tolerate.

Some strategies that you could try are:

• Use fragrance free soap/non-perfumed cleaning products or toiletries or identify cleaning products that your child likes the smell of. It may be a good idea to stick to the same smells and only one smell so that this is predictable and easier for your child to cope with.
• Flush toilet (so no unpleasant toilet smells)
• Allow child to bring something they like the smell of into the bathroom, this could be a toy that they sleep with, a freshly washed gentle smelling cloth or something that is lightly fragranced with a smell that they have already stated that they like. Noise Does your child sometimes appear distressed at different sounds? (Bathrooms can sometimes echo and feel louder). Be aware of your voice, the sound of water being poured from a tap and splashing in the bath, the sound of the shower, the sound of a toilet flushing, closing cabinet doors and sounds from outside if there is a window open.
• Listening to music whilst in the bath can help keep your child calm (Mozart’s classical music for children can be calming but you will know your child best and would know the type of music they respond calmly and positively to.)

Does your child find lighting and other visual inputs in the bathroom overstimulating?

• Reduce the lighting in the bathroom. Consider a dimmer switch or close the blinds/curtains if a lot of light is coming through the window.
• Think about lighting that they like and consider having that in the bathroom during bath time (their own night light, flickering fake candle, projector light)

Vestibular

• Do they sit comfortably in the bath or are they fearful of losing their balance in the water? You may have noticed that your child feels uncomfortable generally with movement such as roundabouts, slides, swings at the play park. They may be reluctant to try things like going on a ride-on toy or a bike or walking/sitting on anything that is unstable. They may frequently fall or loose balance for no apparent reason and therefore they may worry that this will happen in the bath.
• Do they dislike their head being in different positions (going from upright to lying down to rinse shampoo)

Before bath or shower time talk to your child to help them understand what to expect: a sequencing story or a visual chart can be useful. This can be pictures or pictures and words giving step-by-step guidance as to what they are doing. This helps them to learn what to do now and next and helps to keep the routine of bath or shower time consistent and predictable.

For example:

• Before bath or shower time carry out an activity your child enjoys so they feel happy, safe and calm. This could be a game, drawing or watching something nice on TV.
• Keep bath or shower time predictable. If it is always for example after tea and before bedtime, they will get to know that this is what happens and it will come as less of a surprise.
• Have the bath water ready before starting the routine. This way there is no waiting around and the process can be carried out quickly with less chance of anything unpredictable or unexpected happening that may cause discomfort. It would also feel more calming for the child if they are not in the bathroom whilst the bath is being poured as there is less noise and less waiting around.

Keep a sensory record 

If you suspect that sensory issues are affecting the person's self-care skills, keep a record of their reaction to different types of washing or clothing which they have difficulty tolerating. This can help you to adapt their washing and dressing routine to something they are more comfortable with. 

It may be that the sensation of water on their skin from a shower is uncomfortable, so you could try bathing instead or use a preferred fabric for washing, such as a sponge or flannel. Perhaps the smell of a particular soap, shower gel or shampoo is an issue so you could try unscented or hypoallergenic alternatives. Check that the washing powder or fabric conditioner you are using is not irritating the person's skin and try alternatives for sensitive skin if necessary. Perhaps the person is reluctant to wear particular items of clothing because they dislike the feel of certain fabrics or the colour or pattern of the clothing?

With older children, you should encourage them to do as much of the bathing routine as they are able to do. To help them be independent you could try these techniques:

Break down an activity into small steps 

There are two main ways to teach self-care skills by breaking activities into small steps: 

• forward chaining: teaches a skill in small steps from the first activity, i.e. to get dressed in the morning, first you put on your pants, then your socks, etc 
• backward chaining: starts at the last step and works backwards through the activity, i.e. once the person has brushed their teeth, move backwards through each step slowly.
   

Use prompts and motivators 

For instance, if you are trying to teach someone to wash their hands, you could use the prompts below in the following order: 

• physical: hold their hands and wash your hands together 
• gestural: mime washing your hands next to them while they wash their hands 
• verbal: say "wash your hands" or show them a ‘wash hands’ symbol, which you can leave above the sink as a prompt for next time. 

Even if the behaviour or task is very short, if it is followed by lots of praise and a reward, the person can feel positive about their behaviour or skill. 

Try to give praise and rewards immediately and in a way that is meaningful to the particular person. Some people like verbal praise, others might prefer to get another kind of reward, like a sticker on a star chart, or five minutes with their favourite activity.

Use picture symbols 

You may find that you need to leave physical reminders of each activity in the appropriate room permanently, for example, symbols, or written lists of all the different steps for brushing teeth in the bathroom and the same thing for getting dressed in the bedroom.

If you feel that you may need additional equipment to help your child enjoy bathing or maybe you need help just to get them into the bath or shower you should speak to your child’s occupational therapist (OT).

• If there isn’t an occupational therapist working with your child, you should contact OT direct on 0300 555 1384
• Monday to Thursday 8.30am to 5pm and Fridays 8.30am to 4.30pm
• Fax: 01329 282534 Minicom: 0300 555 1390
• Email: OTDirect@hants.gov.uk

There are also websites available that can help such as suggesting aids including bathing such as shower seats and other bathing accessories. See external links on the right.