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Hygiene

As children with autism enter puberty, though, hormones start kicking in – and that can be a problem when it comes to being clean and pleasant.

Dad brushing his son's teeth © Photo by Sara Dunn

As children with autism enter puberty hormones start kicking in – and that can be a problem when it comes to being clean and pleasant.

The big problem is that we have two kinds of sweat glands. Eccrine glands are all over us and produce clean, relatively odorless sweat. In adolescence, though, our apocrine glands get going: these glands, located mostly in the armpits and groin, produce the kind of sweat we associate with BO. A teenager who doesn’t wash is, to put it bluntly, a smelly teenager – and a smelly teenager is going to have difficulty making friends. And unfortunately, this can be a difficult process for a teenager with autism to grasp.

Not all kids on the spectrum have problems with personal hygiene, but it’s not unusual – especially those with less complex needs. What’s going on? Some of the problems are physical, and others are social – but don’t worry, there are ways of dealing with both.

Sensory problems

For a teenager with autism, keeping clean can be surprisingly uncomfortable. Here are some common problems, along with possible solutions.

Problem: Touch. Some kids with autism have very sensitive skin. The sensation of water spraying from the shower, a cold squirt of deodorant, the grinding of hairdresser’s scissors, the prickle of trimmed hair falling onto the skin, the bristle of toothbrushes on sensitive teeth and gums: all of these can feel more uncomfortable than just staying dirty.

Solutions:

  • Try baths rather than showers, and keep temperature changes to a minimum. For instance, keep the temperature of the room and the temperature of the water about even, and perhaps warm the towels up.
  • Try a 2 in 1 shampoo and conditioner: that reduces the amount of rubbing on the scalp.
  • Use goggles to protect their eyes from shampoo and water.
  • Roll-on deodorants are less of a shock to the skin than sprays.
  • An electric toothbrush or one with softer bristles might be easier on the mouth.

Problem: Smell. A strong smell can be overwhelming for someone with autism: if you have a citrus shampoo or minty toothpaste, it might be driving them out of the bathroom. You might also have the reverse problem: some kids with more complex problems can be attracted to the smell of poo, and keeping them away from it (including messing around with their own) becomes an issue.

Solutions:

  • For problems with poo, see the section on toileting.
  • Try different brands of toothpaste and shampoo to see which they prefer.

Problem: Taste. You probably shouldn’t be eating most hygiene products, but toothpaste is an issue. More than that, the taste of the water in the bathroom tap might be causing a problem.

Solutions:

  • Try different toothpastes. Baby toothpastes are often milder-tasting, for instance. (Talk to your dentist about this one. Baby toothpastes tend to have lower levels of fluoride  than adult brands, so they’re not ideal – but if adult flavours are really intolerable, then baby toothpaste is a lot better than nothing.)
  •  If your son or daughter can drink water from other taps in the house, bring some up in a jug or glass. You might also try filtered or mineral water to see if they’re any better. Spitting out the excess toothpaste without rinsing is also a reasonable option.

Problem: Hearing. The sound of running water might be hurting your son or daughter’s ears – or, alternatively, they might absolutely love it and flood the bathroom when you turn your back. They might also be upset by the sound of a barber’s clippers or an electric razor.

Solutions:

  • Run a bath or fill the sink, and only call your son or daughter in when it’s ready.
  • If they need to run water without you, let them use noise-cancelling headphones.
  • For a flooder, you may need to put a padlock high up on the bathroom door. Longer-term, you should probably look into behavioural interventions to discourage this.
  • Experiment with scissors or safety razors instead of electrical ones.

Problem: Proprioception. Autism can mess with your sense of balance and your ability to feel what your body is doing. If you aren’t sure of your balance, standing in a slippery tub is scary.

Solutions:

  • Some kids with autism prefer to wash in a sink, or use the shower bending over the tub. If they’re keeping clean and this works for them, an ‘If it ain’t broke, don’t fix it’ attitude may be all you need here.
  • A chair that lets them sit down in the shower might feel safer. (Assuming it’s good and steady.)
  • For milder balance problems, anti-slip stickers in the tub could be useful. The easiest places to find aids like these are online stores for disabled people and senior citizens.
  •  A reliable bathmat on the floor can prevent slips when getting out of the bath or shower.

Social understanding problems

For people who don’t have autism, the idea that how we look and smell sends a message to other people seems pretty obvious. When a teenager has autism, though, it may simply not have occurred to them.

Unfortunately, teens with autism are also prone to miss on the subtler social signals: a wry face or sarcastic remark may simply pass them by. In this way, they can unintentionally give the impression that they don’t care how they come across or if their smell is bothering people – which makes it harder to make friends. Neurotypical teenagers have often not yet developed the empathy and social skills to be nice about such things, and a teenager with bad personal hygiene and/or poor presentation skills is very vulnerable to bullying.

What to do about this? Some ideas include:

  • Have a visual routine that covers cleanliness throughout the day. (For instance: Morning: brush your teeth, take a shower, put on clean clothes…) If routine is particularly helpful for your son or daughter you might even want to set particular times of day for this – though beware the potential stress that might come if they aren’t able to keep to it because of interruptions at school, for instance.
  • Have another visual routine that covers changing and washing clothes. You might want to include such factors as: how many times you wear each kind of garment before you put it in the hamper (e.g. underpants once, socks once, shirt twice); ‘laundry day’ when the clothes get washed; the process of putting clothes in the wash, taking them out, drying them, ironing them, folding them and putting them away; what to do if clothes get dirty before the end of the day. Whether your son or daughter can wash their own clothes will depend on the individual, but work on the habit of keeping clothes laundered rather than wearing the same thing day after day.
  • Break down personal hygiene tasks into a set of steps to make it easier to remember – for instance, use loo, flush, pull up pants, wash hands, dry hands. Using pictures can make this much easier for your son or daughter to follow.
  • Have hygiene kits for each routine – say, a box for the toothbrush and paste, another for the soap and towel, and so on. You could include pictures of these in the visual routine.
  • Use a mirror to show your son or daughter when they’re dirty. You can either use this for the body – ‘Look, you’ve got food on your face. Time to go wash.’ – or for clothes – ‘You have paint on your jumper. You need to change into a clean one.’
  • Demonstrate how to do things. When it comes to things like showering it may be a bit uncomfortable for your modesty, and you might prefer to have a same-sex parent or carer do that –  it’d be easier for your kid to follow anyway when it comes to things like keeping their private parts clean – but if there’s one great thing about kids with autism it’s that they’re not going to think you’re weird or inappropriate for doing it! (You might, however, want to explain to the family GP, social worker or other trusted authority that you’re doing this, just in case your son or daughter mentions it and someone gets the wrong impression.)
  • Set a timer so that cleaning and self-care don’t get either rushed or drawn out.
  • Use social stories to help your son or daughter understand why it matters. (A social story is an explanation, written in the first person, that imparts a needed lesson. So, for instance: When I don’t take regular showers, I look dirty and smell bad. This makes people uncomfortable and they don’t want to talk to me. I can take a shower every day and then I will look clean and smell nice. People will be pleased with me and I will feel proud because I’m taking good care of myself.)
  • When explaining the rules, don’t forget to include other behaviours that might come under the heading of ‘dirty’ to potential bullies or predators. In public, things like passing gas, talking about peeing or pooing, or taking off clothes in public are all no-nos, and this may need spelling out.
  • Keep an eye out for sexual behaviours which might cause problems. Boys and girls with autism have feelings like everyone else, but they don’t always act on them appropriately; since keeping the genitals clean is a hygiene issue, you can fold some of the sex ed into the hygiene ed. The Vanderbilt Kennedy Center, for instance, recommends a ‘No hands in pants’ rule, possibly backed up by a visual card: if your kid puts a hand in their pants in public, take it out, take them to wash it, and give them something else to keep their hands busy. Alternatively, if you’re home, you give them the choice between ‘No hands in pants’ and going to a ‘Private’ place; realistically, they are going to spend some time fooling around down there (pretty much everyone does in their teens), and the key thing is teaching them where’s an appropriate or inappropriate place to do it.
  • Talk to your son or daughter’s school and see if they can arrange any helpful social skills training.

Boys and girls

Boys and girls have different needs when it comes to puberty, and while some of us may feel uncomfortable talking about them, it’s better to get over that and be clear so that your son or daughter is well equipped to deal with things.

With boys

  • Teach him about wet dreams; if you don’t, there’s a chance he’ll think he wet the bed and be too scared or embarrassed to tell you. Let him know it’s normal, associate it with matter-of-fact things like growing body hair and getting bigger, and teach him what to do when they happen – for instance, changing sheets or underwear and giving his private parts a wash. You may want to use visuals to explain all this. He has no control over whether he has a wet dream or not, so it’s best to be as shame-free and calm as you can: make it clear that they’re not bad but they are private, and focus on how to handle them appropriately.
  • Give some tips about how to deal with unwanted erections – for instance, stay sitting down and wait for it to pass, or cover your crotch with books or a jacket to hide it. You might also look into underpants that fit well; erections are less obvious with briefs than with loose-fitting pants, but let him have some freedom to choose what’s comfortable. He may need you to make it clear that he needs to keep erections discreet in public to avoid attracting negative attention.
  • Help him learn to shave. A picture of the face featuring which parts to shave may make this easier for him. Schedule dates on the calendar, let him watch an older man shave so he can get the idea, and support him while he practices. If he goes overboard with the shaving cream, travel-sized packages might be useful. If he has sensory issues that make an electric razor too unpleasant for him, talk to an occupational therapist: a weighted razor or razor universal cuff might be easier for him to manage.

With girls

  • The big hygiene issue with girls is periods. Many girls find this an anxious area, autism or not, so it’s probably a good idea to teach your daughter the basics before her first period hits. That way, she’ll understand that it’s normal and that that she’s not ‘bleeding’ because she’s hurt.
  • A visual monthly calendar can be a good way to let her know how to predict her period – though you should also explain that periods can be irregular when they first start. You could put one up in the house, or there are calendars you can download onto a tablet or smartphone. (Search for ‘menstruation calendar’, but you might also try ‘ovulation calendar’, as a lot of them are designed for women planning to get pregnant.)
  • When it comes to dealing with the flow, the options are pads, tampons or menstrual cups; your daughter might like to choose her own discreet container to keep her things in. Pads require less fine motor dexterity to manage, so if that’s an issue for your daughter then they might be an easier option, but if her flow is particularly heavy or she has other medical conditions around her menstrual cycle, a talk with the GP is a good idea.
  • Another important issue for girls is starting to wear a bra. The sensation can take some getting used to, especially if a girl has sensitive skin, so a good plan is to get her into the habit of wearing something under her clothes such as a training bra or tank top before she develops to the point of needing a full-on bra. Once you go to buy one, find a shop that does professional fittings: comfort is key here, so what you’re looking for is something that avoids things like itchy lace and underwiring, and that fits well. Bras can get sweaty, so you might want to have a visual schedule to remind your daughter to change her bra and put the dirty one in the wash every few days.

If you’re looking for more resources, there’s a lot of good material in the Vanderbilt Kennedy Center’s ‘Healthy Bodies’ toolkits for boys and girls.

Hygiene and personal care are a sensitive area in our society, and they can be difficult for teenagers with autism to master. However, with patience, support, and a steady refusal to get embarrassed, you can help your son or daughter a great deal – and the result could be a much safer and happier social life.

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