Editor's note: This text-based course is a transcript of the webinar, Updated ADL Milestones In Children Ages 0-6 With Cultural Considerations, presented by Erica Jacoby, MS, OTR/L.
*Please also use the handout with this text course to supplement the material.
Learning Outcomes
- After this course, participants will be able to analyze the significant milestones for the typical development of primary ADLs.
- After this course, participants will be able to differentiate how cultural differences impact ADL development.
- After this course, participants will be able to analyze cultural responsiveness when assessing and intervening with ADL development in families with diverse cultural backgrounds.
Introduction
Thank you all for being here today. I'm excited to talk about this topic. I've been working on the third edition of the Transdisciplinary Play-Based Assessment. We've been working on that as a transdisciplinary team for the last six years, and my research for that project led me to do this presentation today. During that time, I also began working overseas at a school for children whose parents work for the Department of Defense. We have families representing clinical cultures from all over the world at the school and on our base, and it’s been a great learning experience in addition to living daily life in an international community. I also want to highlight that I'm a member of the OT Frontiers Organization, which provides a network for international occupational therapy practitioners to promote the development of occupational therapy in low and middle-income countries. They do some great work, and it’s been an incredible learning experience collaborating with occupational therapy practitioners from all around the world—from South America, Africa, the Middle East—and we do a lot of engaging presentations and learning opportunities as part of that volunteer network.
These are our learning outcomes for today. The first one is to analyze the significant milestones for the typical development of the primary activities of daily living, or ADLs. The primary ADLs we’ll be addressing today are feeding, toileting, dressing, and sleeping, as these are the self-care skills most children are expected to be independent with when they’re six. The second learning outcome is to differentiate how cultural differences impact ADL development—because they very much do—and we’ll talk more soon. The third outcome is demonstrating cultural responsiveness when assessing and intervening with ADL development in families with diverse cultural backgrounds. This is a huge goal, and it will stretch beyond this hour-long discussion and be something that we all will hopefully continue to learn and strive for in our practice after this course is concluded. We’ll talk more about what exactly cultural responsiveness entails in a moment as well.
Reflection on Our Cultures
This is a picture of my family’s land in Figure 1.
Figure 1. The author's family farm.
It’s near the border of Ohio and Kentucky in a region known as the Edge of Appalachia. I grew up in a nearby town, but Appalachian culture was the foundation for my upbringing. I had heard the word “Appalachian” plenty growing up, and yet I had no idea that it was its own culture.
It wasn’t until I was taking a class on culture in my social work program that I became aware of this. We had a textbook that neatly organized each culture into its own chapter. Each chapter talked about that culture’s beliefs, values, things to be prepared for when working with them, how to avoid disrespecting them, and so on. I can’t tell you the utter shock I felt when we got to chapter three or four, which was titled “Appalachian Culture.” And I was even more confused when my professor pronounced it “Appa-lay-chun” Culture.
Then, I was utterly bewildered to see that a perfect description of my family was in black text on a white page. Had they met them? How did they know how to describe them? That day, I became aware that I had my own culture. Culture is a subtle thing.
When we grow up in it, surrounded by it, and don’t know anything different, we can’t even perceive it. It’s not until we step outside of it and see other versions of “normal” that we can look back at it and see what makes our culture unique. I want to take a moment today to give us all time to reflect on our own cultures because we can’t examine cultures outside of our own until we know what our culture is.
Please take a minute to think about these questions for self-reflection.
- What are our social rules, spoken and unspoken?
- What do we value? What do we not value?
- How do we prefer to share information or knowledge?
- What are important symbols or traditions?
- What are our most common spiritual beliefs?
- Who do we view as “others,” and how do we respond to them?
Culture
Let’s discuss what culture means when assessing and intervening with ADLs.
So why must occupational therapy practitioners (OTPs) consider culture in our work with families with young children? A 2023 report from the U.S. Department of Health and Human Services found that census data shows the United States is becoming increasingly diverse. This includes diversity in race, ethnicity, religion, language, and sexual orientation. The report predicts that this trend toward greater diversity will only grow in the coming years.
What stood out to me in this report is the acknowledgment that most current social service models—including those used in occupational therapy—are still largely structured around the values of a white, middle-class culture in the U.S. While those models may work well for some families, they can be misaligned with the cultural values and everyday realities of others. This misalignment can lead to outcomes such as reduced carryover of strategies and higher rates of families discontinuing services altogether.
As OTPs, it’s critical that we recognize how these systemic patterns affect the families we work with and begin to adjust our approach to be more inclusive, respectful, and relevant to the diverse cultural contexts in which our clients live.
Culture Definitions
From the same report, we gain definitions of different approaches to culture that we, as service providers, can use in our work. The first one—cultural competence—is probably something most of us have heard of now. This was the class title I mentioned earlier in my social work program, where I first began to understand that I had my own culture. Cultural competence is increasing awareness, knowledge, and skills along a continuum to improve one’s capacity to work and communicate effectively in cross-cultural situations. It’s important to note that this approach does not generalize across cultures. Instead, it involves gaining cultural competence one specific culture at a time. Practitioners are expected to develop awareness, knowledge, and skills for each culture they interact with.
The next concept is cultural humility. This is defined as an attitude of lifelong self-reflection, eliminating assumptions, and immersing oneself in learning and respecting clients' experiences from their perspectives. Through this lens, we recognize and value people as the true experts of their culture and lived experiences. Believing people when they tell us about their experiences is a foundational aspect of cultural humility.
Then we have cultural responsiveness, which is the application of approaches such as cultural competence and cultural humility to deliver services rooted in respect and appreciation for the role of culture in the individual and family’s beliefs, attitudes, and behaviors. This approach blends the previous two, encouraging us to apply both as needed, continually. It asks us to approach families with an open heart and an open mind, remaining committed to learning and growing in cultural competence while being humble enough to listen deeply and honor the client’s perspective.
This is why cultural responsiveness is included as one of our learning objectives today. Our overall goal is to apply cultural responsiveness when assessing and intervening with ADL development in families with diverse cultural backgrounds.
Culture and ADLs
Now, combining the topics of culture and ADLs, self-care skills consistently show significant differences in age expectations across cultures, including even within cultures that are typically grouped, such as those within Western societies. For example, there are age-related differences in ADL milestones between countries like Norway and Germany, even though both are considered Western nations. Studies conducted with U.S. populations don’t find significant age differences between the sexes for any areas of self-care development except for toileting, where differences are attributed to anatomical distinctions in urinary control. However, in other cultures—such as Spanish culture—there are apparent differences in age expectations based on the child’s sex, which reflect broader cultural values and gender roles. On the other hand, in cultures like the Netherlands, no differences in ADL expectations based on sex were found across any developmental areas, according to a cross-sectional study.
The fourth edition of the Occupational Therapy Practice Framework (OTPF), the most recent edition, strongly emphasizes the importance of cultural considerations in defining successful task performance. The framework reminds us that independence is not always the ultimate goal for every person. For some individuals and families, success may be defined through interdependence, co-performance, or shared and enjoyable experiences.
As we all know, caregivers are the primary reporters and providers when we work with young children on ADLs. They tell us what these daily activities look like in the home and are often the ones carrying over and implementing the strategies we recommend. So, when caregivers come from cultural backgrounds that differ from ours, it's especially important to be conscious and respectful of those differences.
One study in Jordan used semi-structured interviews to analyze how occupational therapy services are delivered within Arabic Islamic culture. The findings revealed that many of these clients preferred exercises over occupation-based interventions. And while occupations are indeed the heart of our profession, what is even more central to occupational therapy is our holistic approach—our ability to consider what is truly meaningful to the client. If exercises are more meaningful and culturally aligned with a client’s values, then that’s what we need to consider when planning and delivering interventions.
Now, we’re going to start exploring some of the developmental milestones. I realize these pages contain a lot of text, and I won’t read every item word for word. Still, I do want to provide an overview of these developmental stages and highlight some of the findings that stood out to me during my review of the literature. I also want to note that the milestone charts I present today are primarily based on Western or U.S. standards. However, where available, global norms have been incorporated. After each chart, I’ll also take some time to review relevant cultural differences and offer considerations for addressing these specific ADL areas with families from diverse cultural backgrounds.
Toileting Milestones
- 1-12 Months
- No bowel or bladder control
- Stool becomes more firm when solids are introduced
- Decreases in nighttime bowel movements (BMs) by 12 months
- 12-15 Months
- Facial expressions or squatting behavior might occur with BMs
- 15-18 Months
- May indicate discomfort when wet or soiled
- Shows interest in others using the bathroom
- 18-21 Months
- Pelvic muscles may be mature enough to intentionally eliminate
- 24-30 Months
- Bladder fully fills before needing to empty
- Some children (especially girls) may begin to engage in daytime toilet training
- 30-33 Months
- Boys begin to engage in daytime toilet training
- Girls demonstrate BM control
- 33-36 Months
- Boys demonstrate BM control; most children require help with wiping
- 42-48 Months
- Able to stay dry most nights
- Completes full toilet routine, including wiping, flushing, and hand washing
- 54-72 Months
- Fully independent; stays dry each night
There is no bowel or bladder control during that first year of life. We tend to see changes in the appearance and consistency of bowel movements depending on what types of foods the child is eating and how their diet evolves during this time. There’s also a shift in nighttime bowel movement patterns. From around 12 to 15 months, we see behaviors like squatting or more obvious facial expressions when children have bowel movements. Some children will even hide during these moments, which many of you have probably seen before.
By 15 to 18 months, especially if the child is already walking, they’re likelier to start indicating discomfort when wet or soiled. Around this age, they might also begin to show interest in bathroom routines, especially watching what others do. Then, from 18 to 21 months, we start to see further maturation of the pelvic muscles, which is an essential step in developing the ability to voluntarily release for urination or defecation.
At 24 to 30 months, the bladder begins to fill before it empties fully, and this is when some children may begin daytime toilet training. In U.S. developmental standards, this is the one self-care milestone where distinctions are made between girls and boys. Typically, we see girls reaching these milestones a little earlier, followed shortly by boys. Between 30 and 33 months, many girls begin daytime toilet training and may even start having more regular bowel movement control, with boys usually following not far behind.
By the time children reach the 33 to 36-month range, most still need help with wiping. It’s not until around 42 to 48 months that we see whole nights without any nighttime toileting incidents, and children begin to carry out the entire toileting routine. That includes undressing and dressing, wiping, flushing, and hand washing. Even then, many children will still need help, especially with wiping. By 54 to 72 months, most children are fully independent with toileting. They’re typically dry through the night unless something else is happening, like illness or a disruption in routine.
As I mentioned, this is the only self-care skill where sex-based differences are specified in U.S. developmental charts. However, when I reviewed articles from other countries—such as Brazil, the UK, and Jordan—those studies either didn’t mention differences between boys and girls or found no statistically significant differences. Girls still tended to start and complete toilet training slightly earlier, but the researchers didn’t report this as meaningful in terms of intervention or outcomes.
I also want to point out that toileting is one of the areas of development that has consistently shifted later over recent decades. There are several possible reasons for this. One is the rise in child-led approaches, which allow children to initiate toilet training at their own pace. Another is the increased number of parents working outside the home, which can change daily routines. Then there are practical factors—like the availability of better-quality diapers and pull-ups—that reduce the urgency of early training. Other influences include maternal age and education level, which are associated with later toilet training initiation and completion.
Cultural Considerations for Toileting
These are our cultural considerations for toileting. First, I want to highlight that across all the articles and countries I reviewed, three primary approaches to toilet training consistently emerged.
The first is the child-led approach, most commonly seen in Western cultures today. In this approach, parents wait until the child shows clear signs of toileting readiness before beginning formal toilet training. This includes watching for cues like discomfort when wet or soiled, showing interest in others using the toilet, or being able to follow basic instructions.
Historically, Western cultures were more likely to use an adult-led approach. This involves caregivers initiating toilet training based on developmental expectations or convenience, rather than waiting for the child to indicate readiness. The emphasis is more on scheduling and routine, and less on observing the child’s signals.
In some cultures, an assisted approach is used, and this one stood out in the literature. This approach can begin as early as a few weeks after birth. In these cases, caregivers are highly attuned to their child’s body cues, routines, and natural rhythms. They become so familiar with their child’s patterns that they can anticipate when the child needs to eliminate and will place them on the toilet in advance. Parents using this method often report that their children are fully toilet-trained before age three. And this is not an uncommon approach—it’s used in many countries, including China, India, various parts of Africa, South and Central America, and some areas of Europe. It’s a culturally established norm in many of these regions.
Family structure and routine also play a role in toileting development. For example, whether a parent works inside or outside of the home, or whether the child attends a daycare program, can influence the timing and method of toilet training. These are essential things for us to ask families about when we’re discussing this aspect of development—what their daily routines look like, who is with the child during toileting times, and what strategies are currently being used.
When assessing a child with difficulties or delays with toilet training, there are several developmental areas to remember. Cognitive skills are critical, particularly the ability to sequence the steps involved in toileting. Fine motor and dressing skills are also a big part of the process. For example, if a child can’t manipulate their clothing independently, they may struggle to engage in toileting routines fully.
Sensory processing is another area to consider. Children with reduced interoception might not accurately recognize internal cues telling them to use the bathroom. Additionally, postural stability and muscle control challenges can significantly affect a child’s ability to hold and release urine or stool with intention and control, and even their ability to sit safely and comfortably on the toilet. All of these factors can impact the success and timing of toilet training, and they should be considered when creating a holistic and culturally responsive intervention plan.
Sleep Milestones
- 1-3 Months
- 8-12 hours at night; 2-7 hours during the day
- Sleep can be appear very active, with frequent wake-ups
- 6 Months
- 10 hours at night; 4 hours during the day
- 50-75% of babies self-soothe back to sleep during the night
- Sleep regressions can occur in relation to motor development (crawling)
- 9-12 Months
- 11 hours at night; 3 hours during the day
- Cognitive development can result in nightmares
- Sleep regressions can occur in relation to motor development (walking)
- 18-24 Months
- 11 hours at night; 1-3 hours during the day
- 36 Months
- Nightmares, night terrors, and sleep walking might begin to occur – can be related to beginning school and cognitive development
- 48 Months
- 50% of children have stopped napping
- 60 Months
- 70% of children have stopped napping
- 72 Months
- 9-11 hours of sleep at night
- No naps unless sick
Sleep is often overlooked as an adaptive skill, yet it plays a critical role in a child’s development and daily functioning. It’s essential to assess sleep—formally or informally—when working with children who have developmental delays, sensory processing differences, ADHD, autism, or other developmental disabilities. These populations commonly experience sleep disruptions, and inadequate sleep can significantly impact growth, emotional regulation, and participation in everyday tasks. Even the most thoughtfully designed occupational therapy interventions can fall short without sufficient rest.
In the first few months of life, infants typically sleep between 8 and 12 hours at night, with an additional 2 to 7 hours during the day. Sleep at this stage is still highly active, marked by frequent wakeups. Around 6 months, infants average about 10 hours of nighttime and 4 hours of daytime sleep, though this varies widely. By this age, about 50% to 75% of babies can self-soothe and return to sleep after waking. Sleep regressions, often linked to significant developmental gains such as crawling or early language, can emerge here.
Sleep consolidates further between 9 and 12 months, with approximately 11 hours at night and 3 hours during the day. Cognitive changes during this stage can lead to nightmares, and like earlier stages, sleep regressions may reappear during bursts of motor or speech development.
From 18 to 24 months, most toddlers sleep around 11 hours at night and 1 to 3 hours during the day. At 36 months, children’s experiences begin to expand dramatically—many are entering school environments or engaging more with the outside world. These new cognitive and emotional developments, paired with a more vivid imagination, can lead to nightmares, night terrors, and even sleepwalking. While these disturbances can be a typical part of development, their intensity and frequency are essential to monitor.
By 48 months, about half of the children have stopped napping during the day. By 60 months, that number increases to around 70%. At 72 months (6 years), children typically require about 9 to 11 hours of sleep per night and no longer nap unless they are sick or especially overtired.
Persistent concerns such as bedwetting, frequent nightmares, or night terrors may point to underlying psychological worries if they are severe, ongoing, or not tied to a particular developmental stage. A referral to a mental health specialist should be considered in such cases. Similarly, symptoms like loud snoring, excessive daytime sleepiness, or chronic difficulty falling or staying asleep should prompt a referral back to the child’s medical provider for further evaluation.
Even if sleep is not included in a standardized assessment tool, checking in with families about their child’s sleep habits and patterns is essential. Understanding this aspect of the child’s routine provides valuable context for their overall occupational performance and helps guide appropriate referrals and interventions.
Cultural Considerations for Sleep
Cultural considerations for sleep reveal how deeply personal and varied bedtime routines can be from one family to another. Sleep isn’t just a biological process—culture, daily patterns, family values, and life experiences shape it.
Significant life changes, such as adoption, moving to a new home, or experiencing trauma, often result in sleep regressions. Like the regressions accompanying developmental milestones like crawling, walking, or speaking, these emotional or environmental shifts can temporarily disrupt a child’s sleep. It’s a regular part of adjustment and not necessarily a cause for concern.
Daily routines also play a significant role in regulating sleep cycles. Factors such as how active the child is during the day, the timing and amount of screen exposure, and what types of calming or stimulating activities occur before bed—like taking a bath, eating, or playing—all contribute to sleep onset. While routines vary widely between families and cultures, one guideline remains relatively consistent: it should generally take no more than 15 to 30 minutes for a child to fall asleep, assuming they are developmentally ready.
Family sleep culture can significantly shape a child’s sleep habits. Co-sleeping with a parent, sharing a room with siblings, or having multiple family members in a shared sleeping space is the norm in many cultures. In others, there’s a strong emphasis on each child having their room and learning to sleep independently. These variations reflect broader cultural values around independence, safety, attachment, and family structure.
Parenting priorities and cultural beliefs directly influence these practices. Studies such as those by Shepard and Owens have shown that a child’s sleep habits are governed not simply by biological maturity but also by the surrounding cultural context and parental expectations.
Conversations about sleep—especially about co-sleeping—are a key opportunity to practice cultural responsivity. These discussions should always be approached with curiosity, respect, and nonjudgment. Rather than assuming one model of sleep is superior, practitioners should focus on understanding what works best for the family and supporting sleep routines that align with developmental needs and cultural values.
Dressing Milestones
- 1-4 Months
- Body parts are easily moved for dressing
- 4-8 Months
- Is responsive to being dressed; might move more or help by lifting legs
- 8-10 Months
- Anticipates next step; might raise arms
- Removes socks and booties
- 10-15 Months
- Holds up arm, foot, or leg to help with dressing
- Finishes pushing pants down once over their bottom
- 15-21 Months
- Helps remove clothing
- Attempts to put shoes on
- Can put on dress-up or oversize clothes
- 21-24 Months
- Removes (untied) shoes
- Puts on loose t-shirts
- 30-36 Months
- Undresses completely
- Puts on shoes (wrong feet)
- Opens buttons, closes snaps and Velcro
- 36-42 Months
- Puts on socks
- Opens zippers, closes large buttons
- 42-54 Months
- Puts on most clothing independently, including correct orientation
- Might need help with tighter or complicated clothes
- Can open and close most fasteners
- 60-72 Months
- Fully independent with dressing
Dressing milestones begin in the early months with passive participation. Between 1 and 4 months, infants allow their limbs to be moved without resistance, making it easy for caregivers to dress them. They’re not actively helping yet, but their flexibility supports the process.
At 4 to 8 months, babies become more aware of the dressing routine. They might assist slightly by moving their arms or legs into clothing. This age also brings the possibility of resistance, not because of difficulty, but because they are more alert and aware of what's happening during dressing.
From 8 to 10 months, anticipation starts to show. Babies may raise their arms in preparation for a shirt or begin removing their socks or booties. They’re becoming familiar enough with the routine to predict what comes next, and this is often when socks mysteriously disappear around the house.
At 10 to 15 months, their help becomes more intentional. They might lift just one arm, foot, or leg at a time and push pants down after being partially lowered. These movements are small but meaningful indicators of growing motor control and body awareness.
Children between 15 and 21 months may help remove more clothing and begin attempting to put on items, especially oversized or dress-up clothes. Loose, playful garments are easier to manage and create valuable opportunities for children to explore dressing more independently.
Children often start removing shoes at 21 to 24 months old, especially if they are untied or slip-ons. They begin attempting to put on looser shirts, inching closer to managing more fitted clothing.
By 30 to 36 months, many children can undress independently. They can often put on their shoes, though there’s about a 50/50 chance they’ll be on the correct feet. They also start opening buttons and managing closures like snaps and Velcro, but buttoning clothing is still developing.
Between 36 and 42 months, children typically begin putting on socks, unzipping zippers, and closing larger buttons more consistently. Their fine motor skills and coordination are becoming more refined.
At 42 to 54 months, they can put on most of their clothes independently. They begin to recognize when clothing is on backward or inside out and try to fix it. They can manage most fasteners if they are large and easy to reach, but may still need help with tighter garments or closures on the back of the body.
By 60 to 72 months, children are generally fully independent with dressing. They can choose, put on, and fasten their clothes and manage different types of closures with minimal or no help.
Like toileting, dressing milestones appear to shift slightly later than previous generations. A study from Denmark published in 2019, which used parent reports from the 1960s, showed that children were buttoning shirts and putting on socks around 30 months old. Today, those same tasks are more commonly seen between 36 and 42 months. This change may reflect cultural differences and evolving expectations around child independence, clothing design, and daily routines.
Cultural Considerations for Dressing
Dressing doesn’t always need to be independent. In some cultures, it remains a shared family task for far longer than Western developmental charts suggest. Parents may choose to dress their children themselves because it’s a moment of connection or simply because they want their child to wear a carefully selected outfit. Wanting to preserve that shared time or prioritize aesthetic preference is valid and should be respected in therapy planning.
An interesting article from an Australian book reviewed the ethical considerations of children’s participation in dressing to go outdoors. It raised the question: Is it ethical to make a child wear a coat if they don’t want to, especially when they’re not at risk of harm? While it’s a familiar power struggle for many families, viewing it as an ethical dilemma brings new insight into how much agency we allow children over their bodies and routines.
Adaptive clothing has become increasingly available, offering innovative features to support dressing for those with physical, sensory, or motor needs. Some of these designs are truly ingenious and have even been developed by occupational therapy practitioners. However, there’s a clear gap in traditional cultural clothing—very few adaptive designs incorporate garments specific to cultural or religious traditions. This can leave families without options that fully honor their identity and values.
Dressing depends on a wide range of foundational skills. Delays or difficulties might stem from cognitive challenges (like sequencing and problem-solving), fine motor coordination, sensory processing (tactile defensiveness), motor planning, or balance. These areas should be carefully considered when evaluating dressing performance or designing supports.
Feeding Milestones
- 1 Month
- Reflexive, increasing to 2+ sucks before swallowing and breathing
- Loses liquid from the side of the mouth
- 2-3 Months
- Jaw, tongue, and lips being to move together
- Drooling increases
- 4-6 Months
- Opens and closes mouth and lips adaptively
- Up-and-down chew pattern emerges
- Pushes food out with tongue
- 6-8 Months
- Helps bring bottle to mouth
- More distinct pattern of chewing
- 8-10 Months
- No longer loses liquid from side of mouth
- Feeds self finger foods using pincer grasp
- Uses lip to clear food from spoon
- 10-12 Months
- Primarily drinks from, and helps hold, cup
- Holds spoon in fisted grasp
- 12-15 Months
- Rotary chew emerges
- Begins dipping spoon and turning upright
- 15-18 Months
- Feeds self with cup and spoon independently, with spilling expected
- 18-21 Months
- Increased lip closure, decreased spilling
- Moves food from one side of mouth to the other
When we talk about feeding milestones, it’s essential to begin by acknowledging what’s not included here—namely, specific food types like purees, baby foods, or table foods. While those are often listed in developmental charts, they can vary widely depending on a family’s culture, preferences, feeding philosophy, access to resources, and even how their approach evolves over time. Because of that variability, this overview focuses instead on the underlying motor, sensory, and self-feeding skills that emerge through development—universally applicable milestones but still profoundly influenced by context.
In the first month, feeding is mostly reflexive. We see that classic suck-swallow-breathe pattern, often accompanied by lots of liquid loss from the sides of the mouth. The baby is just figuring things out. By two to three months, coordination improves a bit, with the jaw, tongue, and lips starting to move together. Interestingly, drooling increases at this stage—something parents often notice and question, but which is completely normal.
By four to six months, babies begin opening and closing their mouths more adaptively, responding to what’s happening around them rather than just moving reflexively. You’ll start to see an emerging up-and-down chewing pattern and early tongue protrusion, sometimes resulting in food being pushed forward or even out of the mouth—again, an important and expected part of oral-motor development.
In the six to eight-month range, babies begin to help bring the bottle or cup to their mouth and show more defined chewing patterns. From eight to ten months, their ability to feed themselves begins to blossom. They start using a pincer grasp to pick up finger foods, lose less liquid from the sides of the mouth, and can use their lips to clear a spoon—rather than having it wiped against the lip by a caregiver.
By ten to twelve months, they’re often drinking primarily from a cup and helping hold it, and they begin to hold a spoon using a fisted grasp. Then, at twelve to fifteen months, something special happens—the emergence of the rotary chew. This figure-eight jaw movement allows them to process food more thoroughly. Fun fact: the jaw and the hips are the only joints in the body that perform this figure-eight movement; fascinatingly, this skill usually appears when children begin to walk.
At this stage, they’re also experimenting with dipping a spoon into food and bringing it to their mouth more purposefully—though spills are still part of the process. By fifteen to eighteen months, many children are feeding themselves with both a spoon and a cup, with some expected mess. At eighteen to twenty-one months, we see better lip closure, less spilling, and the ability to move food side to side with the tongue.
By twenty-one to twenty-four months, wrist mobility develops, allowing children to twist open screw-top lids, and many are drinking from straws. Twenty-four to twenty-seven months marks the emergence of clear food preferences—a time when many parents notice their previously adventurous eater becoming a “picky eater.” This shift can raise concerns, but it’s a completely normal developmental phase. Also, around this age, children can use their tongue to clear food from all areas of the mouth.
Between twenty-seven and thirty months, we see refinement in spoon use with more controlled fingertip grasping, and fork use begins to emerge. Children also start adjusting their mouth opening to match the size of the bite they’re taking—no more giant “monster bites” for every mouthful.
By thirty to thirty-six months, children can now move the bolus—the chewed-up food—around their mouth with control, and they may begin using a napkin to wipe their face. From thirty-six to forty-two months, independence grows. Children might begin helping prepare food, get their own water, or drink from an open cup using one hand.
In the forty-two to forty-eight month range, feeding becomes more effective and neater, with children using both a fork and spoon with less spillage. However, it’s important to recognize that these expectations—around self-feeding and food prep—are shaped by Western norms. In many cultures, feeding continues as a shared activity much longer and isn't seen as a sign of delay.
From forty-eight to fifty-four months, children can hold a fork using a refined fingertip grasp, pour liquids from a larger container into a smaller cup, and begin using a knife to cut soft foods. By sixty to sixty-six months, they can spread soft foods with a knife and may even prepare simple snacks—again, assuming their family supports and encourages this level of independence.
Finally, by seventy-two months, children are typically feeding themselves all types of foods independently and using utensils skillfully, with only occasional spills (because, realistically, spilling never disappears entirely!).
These feeding milestones tell a rich story—not just about motor skill development, but also about culture, context, and connection. As occupational therapy practitioners, when assessing feeding, we must remain mindful of these layers. Feeding isn’t just about skill—it’s about safety, efficiency, and above all, honoring what is meaningful and typical for each family.
Cultural Considerations for Feeding
When considering feeding through a cultural lens, it’s essential to recognize that independence isn’t always the highest priority. In many families, feeding remains a shared activity well into early childhood—not because the child is incapable, but because this time together is cherished as a meaningful bonding experience. In some cultures, it’s completely typical for parents to continue feeding their children until they begin school, emphasizing social connection over skill acquisition.
As occupational therapy practitioners, this context matters. When we assess feeding skills, we must do so within the child’s familiar environment. That means using foods the child already knows and prefers, not introducing new ones during the assessment. The goal isn’t to test adaptability or novelty, but to understand the child’s abilities within their everyday routines.
The same holds for utensils. We should use what the child and family use at home—forks, spoons, knives, chopsticks, or simply their fingers. Each method holds cultural significance and functional value; none should be dismissed as less than. If a child is primarily finger-feeding and that’s developmentally appropriate and safe, we can consider that within their cultural and developmental context.
Regarding drinking, we want to evaluate the child’s use of their highest-level drinking container. This might be a bottle, a sippy cup, an open cup, or something else entirely. But it's crucial to ask families what their child can use, not just what they use most often. Sometimes, there’s a difference between the child’s actual ability and the family’s preferred routine.
At the heart of feeding assessment—whether standardized or informal—are two critical questions: Is it safe? Is it efficient? Feeding is a profoundly complex and culturally shaped activity, and many variables can influence performance: familiarity with the food, current stage of development, and even typical picky eating phases. But no matter what’s happening at the table, our primary concern should always be the child’s safety and efficiency in the feeding process.
By honoring family norms and expectations and assessing within the child’s real-world context, we can deliver more meaningful, respectful, and accurate care.
Summary
As we bring everything back to the family farm—the grounding image we've used throughout—let's take a moment to reflect on the deeper connections we've made between culture and ADL milestones and how these two overlap in meaningful ways.
First and foremost, we need to recognize that understanding our own culture is essential. It shapes what we see as “normal.” If we’re unaware of our norms, we can’t truly appreciate those of others. This self-awareness becomes the foundation for interpreting children's behaviors and developmental trajectories during assessments. Without that insight, it becomes challenging to identify when something truly deviates from a norm, or whether it simply reflects a different cultural expectation.
Practicing cultural responsivity starts with humility and curiosity. It means approaching families not as experts on their lives, but as learners—asking questions, listening with intention, and genuinely believing what they share about their experiences. This blend of humility and curiosity helps us provide care that is not only clinically sound but also deeply respectful and personalized.
Accounting for the cultural context of the children and families we serve isn’t optional—it’s central to delivering holistic, individualized, and meaningful occupational therapy. And this brings us to a core truth we must keep revisiting: independence is not always the end goal. For many of us trained in Western models of OT, independence is seen as the pinnacle of function. However, interdependence is the highest value in many cultures, and we must honor that. Even as someone who has spent years reflecting on this idea, I find myself returning to it regularly as a necessary reminder.
It’s also important to acknowledge that developmental milestones are not fixed—they shift over time. What was once considered “normal” decades ago may no longer be the case today. That’s why it’s essential to rely on current data and culturally adjusted milestones when available. Using outdated charts or tools simply because they’re familiar or accessible can lead to inaccurate assessments.
Speaking of culturally responsive tools, I want to highlight one that consistently appears across global studies: the Pediatric Evaluation of Disability Inventory (PEDI). While there's no official master list of all the countries adopting it, many universities and clinics worldwide have customized the PEDI to reflect their local communities. This includes translating the language and adapting the content to ensure cultural relevance. Officially, PEDI is available in languages such as Dutch, Norwegian, Swedish, Spanish, Portuguese, Slovene, Turkish, Icelandic, French, Hebrew, Japanese, German, and Chinese. The availability of tools in a family's primary language, rather than relying on English-based assessments, can make a significant difference in accuracy and rapport.
In talking with several OT Frontier Network colleagues—particularly those practicing in countries like Uganda—it became clear that many practitioners blend PEDI with their clinical judgment. They look beyond the tool itself to consider family expectations and context. When one developmental area stands out as different but the rest aligns with the family's reported norms, it may simply be a cultural difference—not a developmental delay. And that insight is powerful.
So, my encouragement to you is this: do your research. Learn what tools and approaches best suit the families and communities you serve. Most importantly, trust your clinical judgment—especially when you’re working through the lens of cultural responsivity. That’s how we build skillful practice and truly respectful and effective partnerships with families.
Thank you for being here and joining me in a conversation close to my heart. It’s been an honor to share this space and topic with you.
Exam Poll
1)Which definition best aligns with the concept of cultural humility as outlined in the presentation?
2)According to the presentation, what is one cultural factor that can significantly influence the timing and method of toilet training in young children?
3)Which age is most commonly associated with children beginning to experience nightmares and night terrors?
4)What underlying developmental skill is necessary for independent dressing, as emphasized in the presentation?
5)When assessing feeding skills in children from diverse cultural backgrounds, what should be prioritized according to the presentation?
Questions and Answers
With toileting, you mentioned that the mother's education can impact toileting. What exactly do you mean by that?
Studies have shown a strong association between the years a mother has attended school and the age at which her child begins and completes toilet training. Specifically, the more education the mother has, and the older she is, the later her child tends to start and finish toilet training. While these studies did not specify exact reasons for this correlation, the trend was consistently observed.
Can you please review the differences between child-led, adult-led, and assisted toilet training again?
In child-led toilet training, the process begins only when the child shows signs of readiness. This might look like the child expressing discomfort when their diaper is wet or soiled, or starting to communicate verbally or through gestures that they’ve gone to the bathroom or want to try using the toilet. Caregivers adopting this approach wait patiently for these cues, allowing the child to initiate the transition to toileting.
By contrast, adult-led training is driven by the caregiver’s decision to start toilet training, regardless of whether the child shows clear signs of readiness. This method often involves setting up a structured routine that includes regular bathroom visits, reward systems, and other strategies to prompt the child to begin using the toilet on a schedule.
Assisted toilet training takes a different approach altogether. Here, the caregiver takes a more hands-on role by observing the child’s bodily cues and physically placing the child on the toilet at appropriate times. From a very young age, the caregiver completes most of the toileting tasks for the child. Even though the child isn’t managing the process independently, the routine use of the toilet with assistance is still considered a form of training.
References
See additional handout.
Citation
Jacoby, E. (2025). Updated ADL milestones in children ages 0-6 with cultural considerations. OccupationalTherapy.com, Article 5812. Available at www.occupationaltherapy.com
