Pointer Skills

Pointer Skills...

One area we've been working really hard with Wesley on are his pointer skills. One of the first questions the neurologist and all our development evaluations always ask is does he point to things that he wants. No, actually, he doesn't. He never has. The next question then is, well how does he tell you what he wants? Well, honestly he's not a very demanding kid and he's extremely easy going, so a lot of the time he just moves on. If he wants something or can't get what he wants he whines (no talking yet) until I figure it out for him, or if I'm close enough he'll grab my hand and move it to what he wants or needs. That's obviously not an answer they want to hear and twice now I've been told that could mean he's on the Autism Spectrum. This was extremely upsetting to me, not so much because I care about the actual diagnosis, just add it to the list... but because I feel like he's being labeled based on a behavior that can be explained by a dozen other characteristics he has or deals with (easy going personality, delayed motor skills, no talking, etc).

I think it makes doctors and specialists feel better when they can throw a label on the kid to define their behavior... what I can't understand is how they can possibly think that a simple checklist with yes/no questions can tell them whether a kid has Autism for example. Wesley had a severe brain injury at birth, how can anyone possibly say that his behaviors are the result of Autism and not the consequence of his injured brain? Even more frustrating is that they ask these questions without explaining what behavior they're looking for or what that means. When they ask me whether Wesley points to things he wants, I think about it for a second and say "no, not really." What I don't get an opportunity to explain are the ways he does tell me what he wants/needs. It's only afterward, when I'm home replaying the conversation/appointment in my head, that I get upset for not saying what he is able to do instead of pointing.

Regardless of what it does/doesn't mean, pointing is still a skill Wes needs to learn and we're working working working on it. He can use his pointer finger to do things like hit buttons, light switches, iPad activities, and he's just now starting to use it to point to what he wants when I present him with options. What he can't do is point to something across the room or when he throws something under the couch, for example, he can't point at it to tell me that's what he wants. So, this skill is still a work in progress...

Learning the Basics

Obviously, Wes can only use his good hand to point to things since he has no real control over his fingers with his weak side. One of the first toys/tools we used to get him to use that pointer finger were toys with buttons of course. Toy phones, piano toys, anything with music buttons, etc. He started with the whole hand and slowly got better and better with narrowing down the pointer finger. One toy in particular that has helped with this is his Rainforest Music box that we keep in his crib. As I've said before, Wes is a major music lover and this toy is a major source of comfort for him while sleeping. Once he figured out that he could control the music and lights by hitting the bird button, his pointer finger skills got real good real quick! I highly recommend something like this in the crib if possible since Wes, for example, spends a lot of time in bed either going to sleep or waking up and ends up playing with the box the whole time!!

Another game we play that helps with Wesley's pointer skills is identifying body parts, particularly on the face. He learned the nose and eyes first just with repeated asking and modeling with hand over hand pointing, then he picked up ears, hair, and mouth. We make different buzzing sounds every time he touches his or our nose, which he thinks is a game, so he points back and forth between our noses to get the buzz effect. Unfortunately he's gotten a little bored with this game lately but it was good while it lasted and taught him not only to point, but what each part of the face is... win win.

Our next challenge was getting Wes to point to objects when presented with options (instead of just grabbing what he wants)... not going to lie, this was not an easy task. I had to present him options, then when he went to grab what he wanted I intercepted his hand and modeled the pointer finger to the object before I let him have it. This took a LOT of practice over and over and he was very frustrated when he didn't get his chosen toy immediately... but practice makes perfect and after weeks of modeling, he finally started pointing to his choice once each time we practiced (I think he didn't want to give me the satisfaction of doing it), then twice, then finally he went all in and pointed every time. WHEW!

We've also been working on Wesley pointing to objects in a book to identify things. He's still a little hit and miss, but with certain books (ones we've specifically worked on) he is able to point out the animals on each page. Eric Carle's Brown Bear and Polar Bear books are ones we always read and we've taught Wes that he can't turn the page until he points to the animal first. We also have a lot of those baby's first words, baby's first animals, baby's first sounds, etc books and we use those to practice pointing to different objects that Wes knows or needs to learn. He's temperamental when it comes to participating, it all depends on his mood that day, but we always try!

iPad and Pointing Skills

The real difference maker in the pointer skill department, though, has been the iPad. I never used to let Wes do anything with the iPad except watch a story book when he was younger, but my brother talked me into (demanded really) buying an iPad case so Wes could actually touch and play with it. Let me tell you... BEST PURCHASE EVER! It was $35, (for a CASE, ugh), but worth every penny! Here's the one we got and it's been a life-changer:   Once I put the iPad in that case it became indestructible, LITERALLY!

There are 100 reasons why the iPad has been an amazing tool for Wesley's development, but I'll stick to the pointer skills for now. When he first started playing with the iPad, it was really him watching the screen, not a lot of interaction. So, we had to show him that there was a cause/effect relationship. When you touch the iPad, something happens. Fisher Price Storybook apps are the BEST for this. Actually ALL Fisher Price toddler apps are amazing and free, I recommend downloading every one you can find (I've scour the app store looking for all things Fisher Price). The great thing about the Storybook apps is they sing/read a nursery rhyme one page at a time. So on one of the app's settings, all Wes has to do is hit the screen anywhere and the page turns. PERFECT for cause/effect and teaching him that touching the screen causes something to happen.

Once Wes figured that out, he started to realize that if he touched in certain places, different things would happen. Again with the Storybook apps, they have another setting that allows you to play with the pictures on the screen and you can't turn the page unless you hit the arrow button. All of the Fisher Price apps have similar settings with arrows, characters, and buttons that you can play with and these features have literally taught Wes that he has to use a pointer finger (not the whole hand method) if he wants to do more things with the app. Now, that's not to say he doesn't slap the iPad with his whole hand still... he's a boy and he always tries the easiest method first :) SO, I have to constantly remind him to "use your finger" and many times I still guide his hand and help him point his finger to target certain buttons/areas.

Now what we're trying to teach him is to drag an object with his finger across the screen to complete a task. This has taken a LOT longer for him to understand and he still doesn't quite get it, but I can see him starting to make that connection with some of the apps so we're getting there. I'll dedicate another post solely to the iPad apps that have been fantastic for Wes since there are so, so many and they're all great for development!

At the end of the day, one of the lessons I've learned about pointer finger and other fine motor skills with Wesley is practice practice practice. Even if he doesn't seem to be getting it, learning, trying, or even paying attention, as long as we try even just once a day, over time it will become a routine and he WILL learn it. Patience always pays off!

Addendum to Muscle Development post

I knew I forgot a couple things... here's an addendum to the Muscle Development post....

* Bubbles!!!! Wes has always loved bubbles and I was SO excited when he finally figured out that you are supposed to pop the bubbles!! The way we get him to use his right hand with bubbles is with the bubble stick. I'll blow a bunch of bubbles, then catch a bubble with the stick.... then I have him reach up to pop the bubble with his right hand. I hold the bubble stick up high (to make sure his arm has to go up) with the bubble dangling down, and after repeatedly doing this and prompting him to use his right arm, he's now in the habit of always reaching with his right hand! WIN

* Brown Bear Slide and Find book - I'm always trying to find interactive ways to get Wes to engage in reading books with me and the Brown Bear (slide and find version) book has been FANTASTIC! Each page has a little window that slides open to reveal the animal that will appear on the next page. We read each page, I have him point to the animal on the page, he slides the window open with his left (good) hand, then once we see the animal he uses his right hand to slide the window back closed and turn the page. He needs help with this because he doesn't have control over his fingers or the pressure he needs to slide the window back closed, but at least he puts his right hand up and goes through the motion to complete the task!

Using Those Pincher Fingers

Pincher Skills

I talked about getting Wesley to use his right arm (delayed side) more, but during his last OT evaluation a few months ago I realized we were completely failing to pay attention to his good arm and the skills he needs there, things like pincher skills, pointing, coloring, manipulating things, and more. To keep from making this post ridiculously long, I'll break down each of these starting with pincher skills. Luckily there are more resources out there for these types of activity, so I've done lots of research and solicited ideas from everyone I could find and here's what we've tried.

We've been working on pincher skills for a WHILE now. Wes has thumb/index finger pincher skills, but I've learned there's more to it than that. It's not enough to just pinch something to pick it up, it has to be primarily your index finger and thumb for one. Wes likes to use a combination of his index finger and/or his middle finger to pinch things. Not sure why (and to be honest he's actually pretty good with either), but at the end of the day you're supposed to use your index finger and thumb for most or all pincher activities. So, I did research that putting a sock on their hands with a hole for the thumb and index finger can block the rest of their fingers and force them to use the index finger. I tried this and I think it does work, but Wes (ironically enough) LOVES to chew on anything cloth and I couldn't get him to take his hand out of his mouth.

The number one activity that has seemed to work and still entertains him is the ice cube tray and bottle activity. I dried out a water bottle and filled it with dried beans of all sizes, glass rocks, pom-poms, dice, and straws, pipe cleaners, and wooden skewers all cut into different lengths. Really anything that you can fit in the bottle works!

I shake it and get him all excited, then I empty out the small items into the ice cube tray and the bigger sticks and straws I set aside for the end. He has to use his index finger and thumb to get the items out of the ice cube tray (it's so small he can't use anything else) and then again to put the items back into the bottle, which I shake as soon as he does so he is rewarded and knows he got it in there. He likes to put the items on the table and play with each for a minute sometimes before he puts it in the bottle, but that helps too because he has to pick the item back up off the table with his pinchers (the trick is to try and get him to use his pinchers instead of his whole hand... still working on that). Once everything is out of the ice cube tray, I bring back the sticks and straws and lay them out on the table. Again he has to use his pincher fingers to pick these up because the whole hand scoop is really ineffective for tiny sticks. He has to put each of those in the bottle as well (this helps with coloring skills too, will post about that another time) and finally I let him put the lid on the bottle and we're done!

zippers
stickers
bubbles
puzzles

Building Muscle Strength & Control

IVH and Delayed Muscle Control/Development

Wesley had a Grade 4/3 left to right brain bleed/IVH at birth, which translates in simplest terms to the development of Cerebral Palsy (CP). CP is really just the loss of normal strength and voluntary control of muscles, and the degrees are wide ranging. Wesley is one of the LUCKY ones, his is on the mild side of the CP spectrum. Because his bleed was primarily on the left side of his brain, the delay and tightness is on the right side of his body.

In all honesty, I had resolved myself that Wes would never use his right arm/hand. He had never, in more than a year's time, consciously moved it. Then out of nowhere around 19 months old, he started to move his right arm to turn a light switch off (a task we practiced hand over hand for months). I went NUTS of course.... then proceeded to research endlessly and ask his therapists incessantly about how to get him to use his right arm regularly and why out of NOWHERE he suddenly started using it. Here's what I've found:

Your body develops from your core out to your extremities. Your fine motor skills (using your elbow, wrist, fingers, etc) develop through weight bearing, stimulation, and practice practice practice.  To build those skills, particularly with a developmental delay, crawling and the crawl position are crucial, as are any activities that require the arm to be used at or above eye level.

The reason Wesley suddenly started using his right arm was because he was finally able to hold the crawl position and play in that position (weight bearing on that hand) for extended periods of time (it was a battle with him but he did it). Because he was weight bearing on the hand, the stimulation started working on his right arm from the core out, starting with his shoulder movement. FINALLY!  And with the new found control of his right shoulder, he was able to start crawling with both arms, adding even more weight bearing to his daily schedule.

Although he's still not totally there yet, he can move his right shoulder and elbow with pretty good accuracy and with that he can control where his hand goes. He still can't turn his wrist or use his fingers at all to hold or manipulate things but we're getting there. His OTs believe Wes will develop the use of his right arm/hand by blocking his left hand (with a cast). I somewhat disagree... I think restricting the left hand has helped make him use his right more, giving him practice and better coordination, but the weight bearing and muscle strengthening activities are where he's going to get the initial skill from and what's primarily helping develop his brain and motor skills.

SO, with all that said, here's what has worked for Wesley in the development of his delayed side motor development and what may work for you:

* CRAWLING - all day every day

* Holding the crawl position to play with toys (instead of sitting and playing, make them hold the crawl position to play. Even if they use their good hand to do the actual playing, they are weight bearing on their delayed hand which is what you want!)

* Light switches - every time you leave a room, have them turn off the light switch with their delayed hand, even if that means you do hand over hand with them. It doesn't matter if they're using their whole arm or their hand to turn off the light, any movement at or above eye level engages the shoulder/arm muscles and helps strengthen them!

* iPad games - Wesley is a HUGE iPad fan... put the iPad on the high chair or a table and have them use their delayed side to hit the screen. The higher the iPad the better to get them to lift their arm above eye level

* Reaching for you - this was a VERY delayed activity for Wes but when he finally got it we made sure he reached with BOTH arms, even if I had to reach down and grab his arm every time to show him. Again, lifting the arm up repeatedly helps them develop

* Shirts - putting a shirt on (make them put their arms through the sleeves, even if you help) and taking a shirt off, we tell Wes "put your arms up" before we slide the shirt off so he's lifting his arms up

* Basketball Hoop - We have a mini hoop over the back of Wesley's door and every time we walk out of his room we make him "dunk" by reaching with his right arm and grabbing the hoop. He loves it and he's lifting his arm, win win

* Security Code Pad - We have an old unused security code number pad in our house by our front door, so every time we walk by it he uses his right arm to hit the buttons. He loves it!

* High Fives - his daddy taught Wes how to do a high five right when he started using his right side. Even though he doesn't open his hand and he misses half the time, he still lifts his arm and aims for your hand. We only let him give high fives with his right hand and now it's so ingrained in him he only ever tries with the right hand, wahoo

* Book Pages - When I read board books with Wes I have him use his right hand to turn the pages. This is an easy activity to work on aiming his arm and moving side to side directions, plus it engages him while we read

* Toy Doors - We have quite a few toys with doors that open and close. One of the first things Wes learned how to do with his right arm was close the doors on his wooden block toy (one of the best toys for development we have)



* Car and House Doors - Every time we get out of the car Wes helps me close the car door with his right arm (with a little help of course). Once he started doing that we figured why not help with every door we go through? So now he closes them every chance he gets! This works with cabinets and drawers as well!

* Piano toys - Wes has loved these piano toys from the start for some reason! We have the Baby Einstein one and at 2 1/2 he still plays with it constantly.  Whenever I can I make him use his right arm to hit the piano keys

* Lids/Caps - Wes has a complete fascination with plastic lids of ALL shapes and sizes. Because he has limited use of his right hand we have to pick activities that are simple when we practice using his right arm, and anything with a lid is perfect! As silly as it is, simple things like a Mentos gum bottle that pops open and closed works perfect

* Walkers - Similar to the piano toys, the walkers that have toys on the front of them are ideal. We pulled this guy back out after retiring him once I realized Wes just needed toys he could use his right arm to hit buttons with


* Pop Up Toys - We had an old one of these from a garage sale that Wesley loved. These are great for all kinds of hand manipulation skills but what really worked good for Wes was putting him in the crawl position and letting him hit the buttons with his good hand (weight bearing on his delayed hand), then making him push the pop ups back down with his delayed hand!

* Songs - Wes is a LOVER of music, and especially singing. The first game he ever played using both hands was patty cake.... his own version at least. He ends up clapping by bringing his left hand TO his right hand more than actually moving his right hand, but he has to hold his right hand at mid-line for the left to hit it and it ends up working for him. He claps through most of the song, then lifts his hands up in the air for the "put it in the oven for baby and me" part. The second song he learned was Itsy Bitsy Spider and similarly he claps his fingers together for most of it, but lifts his arms for the water and sunshine parts so it works! Since then he's learned the Wheels on the Bus, On Top of Spaghetti, and a few others! Music and nursery rhymes are a big win in our house!!

I'm sure there are a few more things that I'm not remembering right now so I'll repost if any come to mind! Thank you to ALL the resources out there (primarily our therapists and online development websites) for giving us ideas to try with Wes! At the end of the day I also think just KNOWING he will do it, and making sure HE knows he can do it, makes the biggest difference. Having expectations and push push pushing him every day has moved worlds for Wes.... and of course, lots of patience :)