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Activities of Daily Living in Cerebral Palsy

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Introduction

Activities of daily living (ADLs) are essential self-care tasks we complete every day. ADLs include eating with utensils, toileting, bathing and grooming. For children with cerebral palsy, being involved in ADLs is important for confidence and independence.

Different factors influence a child with cerebral palsy's participation in daily activities. It appears that individual characteristics play a more important role than environmental factors, particularly for self-care activities and participation at home. For example, a child's gross motor function classification (GMFCS), age, and communication function classification (CFCS) most strongly affect their independence in self-care tasks. Meanwhile, their gross motor function (GMFCS), age, manual ability classification (MACS), and cognitive function (IQ) have the greatest impact on how they engage in activities within the home environment.[1]

The effect of cerebral palsy on a child's ability to participate in ADLs often changes as they get older, as the impact of their disability changes over time.[2]

Defining Activities of Daily Living (ADLs)

ADLs are a series of activities we perform each day to take care of ourselves and assist with independent living at home or in the community.[3] ADLs can be categorised as basic activities of daily living (BADLs) / personal activities of daily living (PADLs), which are fundamental self-care tasks, or instrumental activities of daily living (IADLs), which are more complex tasks needed to support independent living.[4][5]

There is no fixed list of ADLs—they depend on the person's age, interests, culture, etc. When working with children, we often refer to basic activities of daily living, including feeding, eating, dressing, toileting, hygiene (bathing, oral hygiene, etc.), and moving around the house.

The definition of ADLs can vary, but most organisations agree on five basic categories:

  • personal hygiene: includes a range of tasks, such as bathing, grooming and oral care
  • dressing: includes the ability to make appropriate clothing decisions
  • eating: the ability to feed yourself; does not necessarily include preparing food
  • maintaining continence
  • transferring: e.g. moving from sitting to standing or getting in and out of bed

Activities of Daily Living and Cerebral Palsy

Newborns depend on their caregivers for their ADLs. As they grow, children become more independent. With time, most children become motivated to do things by themselves and enjoy the feeling of achievement this independence brings. A big part of a caregiver’s role is to help a child gain independence.

Being able to perform ADLs effectively and independently requires many different skills.[6] We need gross motor skills to sit or squat while using the toilet or to lift a leg to put on trousers. We need fine motor skills to undo a zipper, hold a spoon and bring it to our mouth without spilling food. We need visual motor skills for hand-eye coordination while cognitive skills and executive functions are necessary to plan and complete ADLs. We use sensory skills, such as touch, taste, smell, sight, movement and hearing, to explore and make sense of the world. Finally, we use communication skills to follow directions and communicate our wants and needs when performing ADLs. Children with cerebral palsy who are affected in any of these areas may have difficulty performing some or all ADLs.

When working with children with cerebral palsy, it is necessary to understand their functional abilities. The Manual Ability Classification System (MACS) and Gross Motor Function Classification System (GMFCS) can give an indication of what functional skills we might expect a child to develop. Children classified as MACS Level I can handle objects successfully and easily. Children with a MACS Level V cannot handle objects or complete simple actions with their hands.[7] Children with a GMFCS of Level I can walk without limitations whereas children with a GMFCS of Level V will be transported in a manual wheelchair in all settings. Please see the linked texts to find out more about these scales.

Some children with cerebral palsy will need ongoing support with their ADLs, but their parents or caregivers can be given training and support to allow children to participate where they can in ADLs.

Caregivers can use ADLs as an opportunity to (1) encourage participation, (2) address the child's individual needs, (3) motivate the child and set attainable goals, (4) select a teaching style that best suits the child's learning abilities, and (5) establish a daily routine for the child. They can (6) divide the ADLs into parts and (7) ensure that they prepare the environment in which the activity takes place.[8] Each of these seven principles is discussed in more detail in the paragraphs below.

Encourage participation: children should be able to participate in appropriate ADLs. For example, a child who can only use one arm should be encouraged to do as much as possible with their unaffected arm, even if they can't quite complete the task independently. Caregivers should not rush to do it for the child to "save time" or complete the task faster.

Addressing individual needs: caregivers should receive education on how they can use ADLs to focus on developmental skills and activities the child needs / wants to work on. Because these activities become part of the daily routine, the caregiver will be more likely to find time to work on these skills. It is important that the task is appropriate for the child's starting level and that they can develop new skills.

Motivating the child and setting attainable goals: appropriate, achievable goals must be set. These should be motivating for the child to encourage engagement. Capturing pictures or videos before and after practice can be useful to track progress.[9]

Selecting the teaching style: there are three main ways to help children learn to perform ADLs: (1) doing, (2) watching, and (3) listening.[9] Sometimes, it can help to integrate all three of these components and to use other sensory stimuli, such as touch or smell, as well.[9] It can help to incorporate play or discussions into the task. For example, to help a child with putting on a sweater, the caregiver could say: "Today, we will wear a sweater because it is chilly outside. Do you like it when it is chilly? Which colour is this sweater? And what colour is my sweater? Now show me your right arm so I can help you to put the sweater on." When working with children, it's important to give them the opportunity to make decisions. For example, you can ask: "Do you prefer this sweater or this other one?" It can also be helpful to try the tell, show, guide strategy:[9]

  • Step 1: Tell - use simple and understandable verbal instructions to explain tasks or activities to the child
  • Step 2: Show - demonstrate the task or activities to the child, providing a visual example of what you are asking them to do
  • Step 3: Guide - engage in activities together and, if necessary, use the hand-over-hand method to provide direct support and encouragement

When working with children on ADLs, make sure to offer a proper level of challenge, so that the task isn't too easy or too difficult.[9]

Establishing a daily routine for the child: working on specific skills every day will help children master these skills and increase their independence. It can help to have a visual schedule of all activities in the process. Doing daily activities in the correct way (i.e. considering optimal positioning) and in an active way (i.e. so the child is learning) provides many opportunities for the child to learn.

Dividing activities into parts: it can help to divide an activity into a series of sequential actions. This ensures that the child can perform each action separately and in the correct sequence. Once a child has mastered all the components of the activity, they can efficiently perform it in different environments.[9]

Using mirrors allows the child to see what they are doing and better perceive the necessary movements when performing various activities.[9]

Preparing environment: we can adapt the environment in different ways - including physical, sensory and sociocultural aspects. We can decrease or eliminate distracting stimuli.

Finally, it's important that we do not provide too much help. Help with actions the child finds difficult to do on their own.

Assessment and Goal Setting

“The evaluation process is focused on finding out what the client wants and needs to do; determining what the client can do and has done; and identifying supports and barriers to health, well-being, and participation. Evaluation occurs during the initial and all subsequent interactions with a client. The type and focus of the evaluation differ depending on the practice setting; however, all evaluations should assess each client's complex and multifaceted needs.”[10]

Many clinical tools have been developed to assess a child’s performance during ADLs, as well as the underlying motor and cognitive abilities needed to complete these tasks. Often, these assessments are standardised tools that require specific training to be implemented.

The Canadian Occupational Performance Measure (COPM) is used to help children with cerebral palsy and their families identify the activities that are important for them to work on in therapy, including self-care, participating in leisure and play or attending school.[11] It is administered through a semi-structured interview where the child, or caregivers for younger children or those with intellectual disabilities, identify their priorities.[12] The interview is usually conducted at the beginning and near the end of treatment or when a significant change has occurred to measure progress.[13] Allowing children and families to choose their goals is vital to child-centred, individualised care. The COPM is a standardised measure, and the assessment forms and online training modules can be purchased from the company's website.

The International Classification of Functioning, Disability and Health Framework (ICF) can be used to guide the functional status assessment and to establish goals. The children and youth version of the International Classification of Functioning, Disability and Health (ICF) was developed and published as the ICF-CY. This version was designed to provide a holistic perspective on barriers and facilitators that affect a child’s functioning.[14] It was intended to “record the characteristics of the developing child and the influence of its surrounding environment.”[15] You can read about the practical application of the ICF in cerebral palsy here.

The Assessment of Motor and Process Skills (AMPS) assesses how well a person performs specific ADLs in a natural environment. The AMPS is a valuable observational assessment tool, but no AMPS training courses are currently available. Thus, clinicians cannot gain formal certification to use the AMPS. While they can continue to apply similar observational and analytical skills in their practice, this would not be standardised and could affect the validity and reliability of the assessment.

Facilitating ADLs for Children with Cerebral Palsy through Occupational Therapy

A child's independence in daily self-care tasks plays a crucial role in shaping their autonomy throughout life, including for children with cerebral palsy. The ability of children with cerebral palsy to perform ADLs varies based on their motor and cognitive impairments. While complete independence may not be possible for every child in all areas, partial participation in ADLs can meaningfully increase their participation, and decrease their reliance on caregivers in specific aspects of daily living.[16] [17]

Brushing Teeth

Oral hygiene can be challenging for children with cerebral palsy for many reasons, including upper limb weakness and spasticity, difficulties synchronising grip-lift motion, and problems with oral motor function.[18] The following strategies can be useful when helping a child with cerebral palsy learn to brush their teeth.

Adjusted toothbrush handles

Environment and materials: the environment should be comfortable and accessible for the child. Choosing the appropriate brush is important. Some children may require a larger grip on their toothbrush. It may also be necessary to adjust the angle of the toothbrush or extend the length of the toothbrush so the child can more easily reach their mouth.[18] It is also important to consider a child's taste preference when choosing toothpaste. It can be best to avoid toothpastes with a strong flavour initially.

Technique: using the tell, show, guide method can help children learn to brush their teeth. First, describe the activity, then show the child how their parents or peers brush their teeth, and finally, use physical guidance with the hand-over-hand method.

Oral motor activities: teeth brushing requires coordinated movements of the cheeks, tongue, and lips.[9] Introducing different oral motor activities can be beneficial for children with cerebral palsy learning to brush their teeth. Examples of fun games for children include: (1) blowing sponge cubes out of a bowl with a strong blow, (2) putting a little food, like chocolate or yoghurt, around a child's mouth and encouraging them to reach with their tongue and taste the food.[9]

Gripping and brushing: you can help a child practise gripping and brushing motions using laminated picture cards. The child can practise colouring or cleaning pictures of teeth with a brush.

Hand Washing Technique

Hand Washing

The following strategies can help a child with cerebral palsy develop the skills to wash their hands.

Environment and materials: a child can learn to wash their hand in any position, from standing to sitting or while using additional physical support. The key is to ensure that the child is in a comfortable, stable position.[9]

Technique: it is useful to introduce activities that include hand-washing elements to allow the child to practise and use similar movements. Again, the tell, show, and guide method can be useful. First, describe the activity. You can then show the movements involved in washing your hands or use picture cards to divide the activity into small steps that they can copy.

Play: specific games can be helpful, such as asking them to colour their hands with paint, and then getting them to wash it all off.

If you would like to find out more enjoyable play activities, please see: Learning Through Play with Cerebral Palsy.

Bathing

Bathing a child with cerebral palsy can be stressful. It can be challenging to handle a wet child on a slippery surface, especially when a child has spasticity or involuntary movements. The following ideas may be useful when helping a child with cerebral palsy to participate in bathing.

Paediatric Bath Chair

Environment and materials: preparing the environment helps to reduce risks and make the activity more enjoyable for a child and their caregiver. Anti-slip coatings in a bathtub or shower may help to prevent falls. Assistive technology products, like bathing seats, provide support for children who cannot stand and allow them to use their arms freely. Ensuring a child's privacy is essential, especially when children reach puberty.

Technique: children should be encouraged to do as much as possible to increase their independence. For example, they can hold a wash sponge in their hands or a water bottle.

Play: when working with children, it's important to include fun activities to increase participation and engagement. For example, the child can wash their doll or try role-playing games, such as playing hairdressers.

Toilet Use and Hygiene

Many children with cerebral palsy can develop continence, but they might achieve it later than other children.[19] When working on toilet training, parents need to remember that physical and emotional readiness, rather than just calendar age, are crucial. Signs of toilet training readiness include the following: (1) the child can stay dry for at least two hours at a time, (2) they are aware of the difference between being wet and dry, (3) they are capable of reaching the toilet or potty in time, potentially with help, (4) they can undress and dress themselves or are ready to learn, and (5) they are motivated to take this step.

Environment and materials: there are various adaptations for toilet seats and other specifically designed devices for children who lack the motor control to stay seated on a toilet. These products often come with adjustable straps, safety rails, and soft cushioning to help improve safety and reduce the risk of the child slipping and falling.[9] It can also help to select clothes that are easier for a child to pull up and down, such as using pants with an elastic waistband rather than buttons.

Toileting sequence

Technique: teach the child to consistently use a specific cue for getting to the toilet (e.g., use the same word, gesture, or sign every time). The child also has to learn each element of going to the toilet, including hygiene rules, and washing their hands after using the toilet. A visual schedule that shows each step of going to the toilet can be useful.

Dressing

The following strategies can help a child with cerebral palsy learn to dress.

Environment and materials: consider different positions when dressing to ensure body stability and safe posture. Getting dressed in a sitting position and using solid furniture or a wall for support may be appropriate for a child who has problems with balance and coordination. If it takes a long time to practise geting dressed, it's best to find a time when the child is relaxed, like before going to bed or on weekends.

It can be helpful to put labels on clothing to show the front and back or left and right. Arranging clothes in the order they should be worn may help with task completion. Adaptive equipment, such as a sock aid and loop for tying the buttons and loose or elastic clothes with large openings for the head, can be beneficial.

Technique: when teaching a child to dress, use the same sequence every time. Model the activity and provide enough time for the child to practise the activity. As they learn, give step-by-step instructions. For some children, it can help to provide physical support. Using a mirror is also beneficial as it allows a child to see what they are doing.

Play: introducing games can provide more opportunities for practice. For example, give a child pipe cleaners that are pre-made into circles. They can practise putting these circles on and off their arms or legs.

Eating and Drinking

Eating and drinking are essential skills. If you would like to learn more about feeding and eating for children with cerebral palsy, please see: Feeding and Eating Considerations in Cerebral Palsy.

Multidisciplinary Team and ADLs

Many factors influence our ability to perform ADLs. We need to be able to sustain specific postures and control movement at different segments of the body. Many members of the multidisciplinary team work with occupational therapists to help children with cerebral palsy achieve their ADL goals. For instance, physiotherapists can help caregivers understand a child’s movement patterns and posture and find ways to optimise function. Nurses and physiotherapists can help caregivers understand safe, comfortable handling skills during self-care tasks. Speech and language therapists can help children with cerebral palsy enhance their ability to communicate, which reduces frustration and improves participation in everyday activities.[20]

References

  1. ↑ Alvandi F, Amini M, Ghafarzadeh Namazi N. Factors Affecting the Independence Level of 4-6-Year-Old Children with Cerebral Palsy in Activities of Daily Living. Iran J Child Neurol. 2023 Fall;17(4):93-104.
  2. ↑ Saleem S, Ullah DE, Noreen H, Khan DSG, Ashraf S, Tahir A. Frequency of Problems in Activities of Daily Livings in Children with Cerebral Palsy. JRCRS 2022; 10(1).
  3. ↑ Towards a Common Language for Functioning, Disability and Health ICF. https://www.who.int/classifications/icf/icfbeginnersguide.pdf [last access 3.01.2025]
  4. ↑ Edemekong PF, Bomgaars DL, Sukumaran S, et al. Activities of Daily Living. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470404/ (accessed 3 February 2025).
  5. ↑ AOTA. Occupations. Available from https://www.aota.org/advocacy/advocacy-news/coding/~/media/391EBF0C2F39446E908A525CA22272B0.ashx (accessed 27 December 2024).
  6. ↑ Sutapa P, Pratama KW, Rosly MM, Ali SKS, Karakauki M. Improving Motor Skills in Early Childhood through Goal-Oriented Play Activity. Children (Basel). 2021 Nov 2;8(11):994.
  7. ↑ Cerebral Palsy Alliance. Manual Ability Classification System (MACS). Available from: https://cerebralpalsy.org.au/cerebral-palsy/manual-ability-classification-system/ (accessed 4 February 2025).
  8. ↑ Pashmdarfard M, Richards LG, Amini M. Factors affecting participation of children with cerebral palsy in meaningful activities: Systematic review. Occupational therapy in health care. 2021 Oct 1;35(4):442-79.
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 Chumburidze N. Cerebral Palsy and Activities of Daily Living Course. Plus, 2025.
  10. ↑ Occupational Therapy Practice Framework: Domain and Process—Fourth Edition. The American Journal of Occupational Therapy, 2020, Vol. 74 (Supplement_2)
  11. ↑ Russel E, Liu C, Woo L. Associations Between Canadian Occupational Performance Measure (COPM) Change Scores and Cerebral Palsy Functional Classification System Severity Levels. The American Journal of Occupational Therapy, 2020; 74(4_Supplement_1): 7411505128p1.
  12. ↑ Kang M, Smith E, Goldsmith CH, Switzer L, Rosenbaum P, Wright FV, Fehlings D. Documenting change with the Canadian Occupational Performance Measure for children with cerebral palsy. Dev Med Child Neurol. 2020 Oct;62(10):1154-1160.
  13. ↑ The Canadian Occupational Performance Measure. FAQs. Available from: https://www.thecopm.ca/ufaqs/5-how-do-i-decide-when-to-do-a-reassessment/ [last access 2 February 2025).
  14. ↑ Adolfsson M, Sjöman M, Björck-Åkesson E. ICF-CY as a framework for understanding child engagement in preschool. InFrontiers in Education 2018 May 31 (Vol. 3, p. 36). Frontiers Media SA.
  15. ↑ World Health Organization. International Classification of Functioning, Disability, and Health: Children & Youth Version: ICF-CY. World Health Organization; Geneva 2007.
  16. ↑ Gagné-Pelletier L, Poitras I, Flamand VH, Mercier C. Reliability of an observation-based scoring grid to assess bimanual performance during unstandardized tasks in adults living with cerebral palsy. Disability and Rehabilitation. 2024 Jul 30;46(16):3733-8.
  17. ↑ Donohoe M, Hove P. Activities of Daily Living Supports for Persons with Cerebral Palsy. In: Miller, F., Bachrach, S., Lennon, N., O'Neil, M.E. (eds) Cerebral Palsy. 2020 Springer, Cham.
  18. ↑ 18.0 18.1 Palanisamy S, Cholan P, Ramachandran L, Tadepalli A, Parthasarsthy H, Umesh SG. Navigating Oral Hygiene Challenges in Spastic Cerebral Palsy Patients: A Narrative Review for Management Strategies for Optimal Dental Care. Cureus. 2023 Dec 9;15(12):e50246.
  19. ↑ Baram M, Zuk L, Stattler T, Katz-Leurer M. The Prevalence of Bladder and Bowel Dysfunction in Children with Cerebral Palsy and its Association with Motor, Cognitive, and Autonomic Function. Dev Neurorehabil. 2023 Apr;26(3):155-162.
  20. ↑ Cantero MJ, Medinilla EE, Martínez AC, Gutiérrez SG. Comprehensive approach to children with cerebral palsy. Anales de Pediatría (English Edition). 2021 Oct 1;95(4):276-e1.
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