Self-righteous observers tend to impose their own values on the objects that people with a cognitive disability enjoy holding. They need to be told that when the person with a cognitive disability is happy and occupied, that is what matters. The objections of onlookers to teething toys are selfish when they ignore the fact that the person with a cognitive disability is pleased. We all need to get our own value judgments out of the way and focus on the experiences of the person with a cognitive disability.

Objects that capture their attention are divided into two classifications: one hand or both hands.

Grab bars come to the person's attention when they feel unsteady or when cued to use them by a caregiver. This category includes parallel bars, rails on stairs and beds, sinks, and counter tops. Checking the stability of these objects as well as the exact location of chairs requires the assistance of a caregiver. Unstable objects, such as bedside tables on wheels, need to be removed.

Hitting and kicking to ward off objects can be applied to punching bags, bean bags and balls while sitting. They will probably recognize and say the names of targeted objects.

Spatial orientation expands to include the dining room and the garden. A sense of confinement is formed and persistent rattling and banging may follow. Blocking or covering windows can prevent this sometimes. Banging can be interrupted by: taking them out of the unit or out of doors, walking them around in a circle and escorting them back in.

Their expected task performance is driven by their need to grasp and hold an object while walking incessantly. If they are not provided with objects easy to grasp they will try to grasp other objects like other people's wrists or door knobs. Other people are often quite fearful when this happens. Giving the person time to relax will result in them releasing their grasp.

The best measure of sustained attention may be observed with upper extremity range of motion exercises and the time it takes them to do 10 or more repetitions before they need to rest.

At the present time, there are two measures of response time that are needed:

• The time it takes to grab onto an external support, such as a grab bar, when they feel out of balance. This may be a self-protective response, which would be faster than a self-determined response.
• The time it takes to grab onto any object within their arms reach, when balance looks stable. This too might be classified as self-protective or a separate classification of automatic. The same times would support the idea that grabbing is self-protective.

Within ACL 2.8, attention is captured by: a vertical sense of balance, big visual cues below the knees and external objects that pass within their arms reach. The process of evaluating the information in their hand probably takes at least 5 seconds. If they compare their current experience with past experiences, their lack of ability to speak makes it hard to guess what they are thinking. What we observe is a lack of ability to make a choice between maintaining a strong grasp and releasing their grip.

Further observations show that people functioning within ACL 2.8 reach out and grab on when their balance is fine. There must be another explanation for this behavior. Reaching out and grabbing are automatic uses of their hands. A difference is made between automatic and intentional grasp. Automatic grasp may not engage cortical pathways. Cortical control of intentional grasp is described within ACL 3.0.

The person will hold onto a supportive grab bar or bed rail when directed. The direction may be verbal or a gesture such as pointing, but does not have to be hand-over-hand assistance.

To Verify

Sustained attention to grasping and moving can be verified by rote learning upper extremity range of motion exercises bilateral exercises. When done twice a day for 4 or 5 days, they should be able to follow the routine with a few cues to get started.