Attention Magazine April 2024

Hygiene is often difficult for individuals who have ADHD due to their brain and body differences. Tasks like showering and brushing teeth are low-reward activities that involve sensory input that doesn’t always feel good. Most adults with ADHD can remember spending more time trying to trick their parents that they brushed their teeth than actually brushing their teeth.

Over time, parents often get frustrated with their child’s “resistance” to showering and brushing teeth, and can sometimes lose their temper or resort to punishments, neither of those being supportive nor helpful for the child with ADHD. This creates an environment of frustration, power struggles, and demands around hygiene that can last into adulthood.

Do you struggle with these tasks, or are you parenting a child whose ADHD affects their hygiene? The information and tips shared in this article can help you understand and improve the experience of showering, bathing, and brushing teeth.

Sensory challenges
We have eight sensory systems, and individuals with ADHD have at least one or more sensory differences. When it comes to hygiene activities, these differences may include:

• Sensory dysregulation with being wet (especially wet hair)
• Sensory dysregulation with temperature changes
• Sensory dysregulation with changing clothes
• Sensory dysregulation with changes in head positioning (tipping head back to rinse hair)
• Sensory dysregulation with varying pressure and the varying timing of water touching different parts of the body
• Sensory discrimination difficulties with feeling all body parts (proprioceptive awareness), which makes it difficult to thoroughly wash body and hair, and the individual may miss areas or not thoroughly rinse. This can also make it hard to gauge force, and they may squeeze too little or too much body wash and shampoo out of the bottle.

Oftentimes, the individual will love being in the water (bath or shower), but the transition in and out of water can be painful, with sensory overload due to over-responsive sensory systems and sensory discrimination difficulties. Their brain will want to protect them from the intense discomfort they experience, and they will avoid showering. This can turn into a common conflict for a parent/child relationship and creates a repeated negative experience around bathing.

However, the opposite can be true. Showering and taking baths is very regulating, especially for those who are hyposensitive and need more stimulation and/or input.

Executive functioning challenges
There are a lot of steps that go into showering, which can create overwhelm if you do not have a system that works well for your brain and body. Trying to remember all the things you need to do and motivating yourself to do so is really challenging. Among these executive functioning (EF) challenges:

• Remembering everything you need to shower and all the steps (EF: organization and planning). Someone might jump in the shower and forget to have a towel handy or that their shampoo is empty. Having to repeat steps can be frustrating and/or add to the sensory overload—for example, what to do if there is no towel close by.
• Showering requires inhibition (self-control) of stopping a current task and initiation to transition and start the next task, showering.
• The default mode network (DMN) does not turn off for ADHD brains unless there is a high reward or on medication, according to one study. Generally showering is removing you from something more fun and engaging (at least as a kid), so there can be a lot of resistance to transitioning to a less-fun task. It also doesn’t have a big enough reward for many ADHDers for them to engage in the task. Knowing that you will “feel better” when clean isn’t a big enough reward unless you are caked in mud or something that is a sensory “ick.”

Tips and tricks for sensory challenges
First, let’s look at are some tips for addressing sensory challenges.

To reduce dysregulating input

• Use space heaters to reduce temperature changes when coming in and out of shower.
• Skip hair washing; dry shampoo is a great way to lengthen the time between wet hair washings.
• Skip shaving.
• Baths reduce the impact of temperature changes, changes in water pressure, and wetness, as the person has more control over how fast or slow they submerge their body.
• Warm large soft towel that can be accessed quickly; towel warmers are great for this.
• Use a hair towel to keep wet hair off skin.
• Using a handheld shower head to control where the water is spraying on the body,
• For those who have lower body awareness, provide shower or bath hand mitts to wash body and scrub hair; this makes it easier to feel where they are cleaning.
• Have a small mirror in the shower or use the bathroom mirror for visual feedback; this will help them make sure they didn’t miss any spots.

To increase regulating input

• Do a proprioceptive activity beforehand to help move into or increase regulation. This helps the body be in a more regulated state when exposed to uncomfortable/painful sensory stimuli, which makes it less dysregulating. Exercise is a good way to get a lot of proprioceptive input. As a bonus, sometimes having the sensory “ick” of sweat will increase the reward of showering.
• Bath and shower bombs with favorite scents
• Music can add regulating sensory input; as a bonus, it can also help with speed of showering depending on the speed of the music.

Executive functioning tips
Here are some ways to help when executive functioning challenges affect hygiene activities.

Increase reward
Pair bathtime with something they (or you) like to do or enjoy (dopaboosting):

• Listen to music, podcasts, or watch TV in shower/bath.
• Use a phone holder for a shower and scroll TikTok.
• Watch a show on an iPad when they (or you) take a bath.
• Use fun shower spray that smells good or something that feels rewarding and enjoyable in the shower to incentivize the experience. Candles can be fun but also hazardous if you know you easily forget to blow them out.
• Celebrate any little success, even if they (or you) just get physically close to the shower.

This increases the reward (dopabooster) and can distract from some of the sensory challenges (if present).

Build a routine
Routines need support to build and will require a little novel sparkle every three to four weeks.

• Pair showering with something that you or your child already do.
• Write out or make fun visuals of the steps to take and the reward at the end (a supportive parent/partner/roommate can help with this).
• Keep all shower items visible and easily accessible. Installing corner shower shelves helps keep items accessible and visible. Set the items out in the order of use, so it’s not necessary to think about it. Use a clear wall mounted dispenser to put shampoo, conditioner, and body wash in; that way, it’s easy to see how much is left.
• Habit Stack: Have an extra toothbrush and toothpaste to avoid the transition time.
• Reduce the number of things to do in the shower. Start with just rinsing off. Often it is just starting the task that is difficult. Decreasing the “goal” to just rinsing off might lead to doing all the other steps.
• Try setting up a challenge. Take the shower before a short upbeat playlist ends or get in the shower before the song ends. Race a timer.
• Adults can try having an accountability partner or body double. (Showering with a partner can make it more fun!) Any positive friend or partner that is able to check in and give feedback is so helpful in establishing new routines. Using body doubling groups can help as well.

An individual’s sensory regulation is always fluctuating, so some days it may feel easy, while other days it may feel like too much.

All of these tips will require executive functioning skills, and it can be hard to overcome these challenges alone. If it takes a lot of effort to incorporate these tips, that means you need some professional support, and that is okay. It is easiest to build these skills with an ADHD coach, ADHD therapist, or an occupational therapist who specializes in sensory processing. If you struggled with bathing in your childhood and received negative messages or punishment when you resisted bathing, you might want to explore trauma responses with a therapist.

Everyone deserves to learn methods that work for their brain and body. Not all people with ADHD experience all of these sensory differences. An individual’s sensory regulation is always fluctuating, so some days it may feel easy, while other days it may feel like too much. Let your primary supportive relationships know about your struggles and encourage them to learn about ADHD. ADHD-affirming relationships are huge supports and are needed when learning new things.

Anita Robertson, LCSW, is a psychotherapist in Austin, Texas, and the author of ADHD & Us: A Couple’s Guide to Loving and Living with Adult ADHD. She is the creator of the ADHD Relationship Bootcamp to help neurodiverse couples develop new skills to improve their relationships. She believes in the power of a relationship to transform people’s lives in meaningful ways and loves seeing couples grow together. She received her Master’s in Social Work from the University of Texas at Austin and her Bachelor of Arts in Psychology from the University of Rochester. She loves spending free time with her family, hiking, traveling, and socializing.

Carrie Comstock, OTR, is an occupational therapist based in Austin, Texas. She strives to use a neurodiversity-affirming and strengths-based approach in her practice with neurodivergent children and adults.