The information on this page is for professionals who work with young children in nurseries, playgroups and other early years settings. It focuses on hemiplegia, but much of it will apply to children with other complex needs.
Creating an inclusive nursery
"Soap box time, but if small people know that children like Aimee can attend nursery and school with them maybe their reactions will continue to be warm and we will have less restricting attitudes in our adults!" - says a parent of a three-year-old.
Early years workers may think they need to know about a wide range of conditions, and this may hold them back in feeling able to welcome and include all children. In fact, including disabled children is more of a case of extending ordinary good practice and recognising that all children have interests, ideas and aptitudes while supporting early years workers working with the more complex impairments.
In a successful inclusive nursery there is a positive attitude towards disabled children where staff support and encourage children to reach their potential. In order to achieve this staff need to:
- Understand the needs of children with hemiplegia, both in terms of the condition and how it might affect a child's learning and development.
- Ensure that the environment and activities are accessible for children with hemiplegia.
- Know where to go for further information and advice.
- Have a proactive, planned approach to inclusion generally rather than reacting to individual referrals.
- Take into account the needs of disabled children when making changes to the environment or buying equipment or furniture.
- Review policies and practices to ensure that they do not discriminate against disabled children.
- Focus on the free aspects of childhood, which can be easily overlooked amongst all the special treatment that a disabled child might receive.
- Address the mistaken belief that all children with hemiplegia need one-to-one support.
- Look at each child as an individual and not just a 'batch of needs'.
What to expect from children with hemiplegia?
Find out about hemiplegia and its symptoms.
At this age it is mainly their physical differences that distinguish children with hemiplegia from their classmates. But there are other difficulties known to be commonly associated with hemiplegia, which may or may not be apparent at this age. These include speech problems, visual perceptual problems, specific learning difficulties and emotional and behavioural problems.
For many children, these problems can be more frustrating and disabling than their physical difficulties. Obviously, the earlier they are identified and addressed, the better the chances of successful intervention, and nursery teachers are ideally placed to pick up early signs of potential problem areas.
Many everyday tasks, such as eating, dressing and going to the toilet are more difficult if you have only limited use of one hand. The children may need more help and take more time in these areas, and may need to have the tasks broken down into stages to help develop the necessary skills. For example:
- Child struggles to try to pull up trousers
- Pull trousers up nearly to waist and support child to use both hands to get the final part done
- Trousers over bottom and let child pull rest of way
- Trousers to thighs and then child pulls rest of way
- Child pulls up trousers by him/herself
At the same time, teachers and helpers should try to resist the temptation to do too much for the child: the aim should be to encourage independence.
Children with hemiplegia are just like all other children and simple solutions are often the most effective. Some people find it tempting to overprotect a disabled child. It is easy to make assumptions about capabilities. Children with hemiplegia are usually much more robust than we think!
The ideas here are only suggestions. Every child is unique, and you - working in partnership with parents and professionals - will find particular ways of dealing with these practicalities that work for that child!
- Do with the child not to the child - remember all activities are also learning experiences.
- Establish a toilet training routine - unless told otherwise delay in toilet training is not a medical experience, but usually a lack of opportunity or experience.
- Encourage hand/eye co-ordination - ask children to reach for things, don't just give them to them.
- Always give more time to achieve any physical task.
Handling a child with hemiplegia
These suggestions are about how you lift, carry, hold and position a child and learn to control any muscle stiffness or uncontrolled muscle movements. The best way to handle a baby or young child depends on age, type of hemiplegia and how the body is affected. Here are some suggestions, by no means exhaustive:
- Try not to move the child suddenly or jerkily. The muscles may need time to respond to changes in position.
- Some children's muscles tense (spasm). Let muscles tense and relax in their own time - don't force movements.
- Fear can make muscles spasm worse, so give the child as much support as he needs when you are handling him, being careful not to give him more support than he needs.
- Whatever his size or level of impairment, make sure that he spends time in different positions
- Try to position the child so that he can see what is going on around him.
- Many physically disabled children are greatly advantaged by properly fitting and supportive seating.
- As a general rule, feet should be flat on the floor, knees bending at right angles, with hips firmly against the back of the seat. Some children benefit from chairs with arms.
- Some children are particularly sensitive to losing their centre of gravity during rapid growth spurts and they can become clumsier and may be more disorganised.
- Physiotherapists and occupational therapists will advise on the appropriateness of any arrangement for an individual child. They may need to show staff how to handle or carry a child in a way that will help him develop the best possible control over his body, and prevent staff back strain or injury.
"People assume that if a child is disabled they want to spend all day in the same place - but disabled children have just the same aspirations - they want to see the changing world around them like everyone else. They just need physical help to get there!"- says a parent.
Eating and mealtimes
Some children with hemiplegia cannot suck and swallow and chew easily, so eating may be messy. It may also take longer but it is important to take time to ensure that the child has a healthy diet. A health visitor can advise, and a speech and language therapist can give specialist help and support if a child has difficulties when eating.
Trying to encourage children to be as two-handed as possible begins from the moment they start to feed themselves. It is important to reinforce this. Children need to be reminded to drink holding the beaker with both hands, and if eating with only one hand, to place the other hand flat on the table. A non-slip mat may help to anchor the plate.
Staff may be the first to encourage a child to feed himself or to make choices about food and drinks. There are special cups and pieces of cutlery that may be helpful. They may already be in use at home or parents might have brought them in, but a health visitor or occupational therapist will be able to advise.
Brushing teeth is particularly important when children have eating difficulties, since food can easily get stuck in their teeth and gums, and this can lead to tooth decay and gum disease. It may be worth checking the roof of the mouth if food has a tendency to become lodged there. Try to help the child brush his teeth after every meal and cut down on sugary food and drinks.
"It is a good idea to focus on low-tech aids that all children can use that don't highlight differences - things like Velcro and rubber suction mats." - says a parent.
Going to the toilet
Toilet training may be more difficult for a child with hemiplegia. For example, it may be hard for him to relax or use his muscles to empty his bowels. Continence can sometimes be a problem, too. A therapist or health visitor can give him help and support.
Getting dressed or changing clothes can sometimes be difficult for children with hemiplegia. It is likely that parents will already have discovered the practicalities of loose, comfortable clothing. Velcro and elastic can be easier to manage than buttons and zips. There are also specialist suppliers who design clothes with the needs of disabled children in mind.
- Always put the clothes on the most affected side of the body first.
- If their legs are bent before putting on socks and shoes it may help ease any stiffness in her ankles and feet and her toes are less likely to curl under.
- Encourage the child to do things for themselves, even if it takes longer, and give lots of praise for every achievement, however small it is.
See also our advice on dressing.
"Communication falls into the same category as food, drink and shelter - it is essential for life, and without it life becomes worthless." Anne McDonald, campaigner.
Most of us who use the common form of communication ignore the many other methods of communicating, such as signs, symbols, behaviour, hand / eye-pointing, facial expression. This is called unaided communication. It does not involve any external materials or equipment, and is used by all of us unconsciously when speaking.
Disabled children are not always able to use the full range of unaided communication. They still express the same feelings, albeit in a modified manner, such as going into extension spasm with excitement. Aided communication is called augmentative communication and refers to techniques, symbols and strategies, often referred to as low-tech, that are needed to aid children with a communication need.
Augmentative and Alternative Communication (AAC) is a means of replacing spoken words by an individual. It can range from a movement or behaviour that is interpreted as meaningful, to the use of code agreed between people where items have specific meaning, i.e. language.
- Don't be afraid to speak directly to the child.
- Encourage eye contact.
- Say the child's name clearly as a way to start each communication.
- Find out what communication method the child uses and consider how to use it across the whole setting.
- Never underestimate parental experience.
- Encourage and give time for speech and / or vocalisations.
- Give children the chance to be active in their communication by giving choices.
1Voice Communicating Together is run by parents for users of low-tech and electronic communication aids and it offers information and support.
Communication Matters is a charitable organisation which covers the whole of the UK.
I Can is a collaboration of three communication organisations. In particular it provides information on adapting the environment.
AbilityNet gives advice on using computers through assessments, workshops and courses. It also has an extensive list of communication aid assessment centre / services.
Play and learning
"Once I saw that Helen could play, I stopped seeing her as a syndrome, a problem, and saw her as a child with imagination, ideas and potential." - says a parent.
All early years settings know that play is vital for all children. It is the way we explore the world about us and our place in it offering opportunities to relax, express feelings, experience success and failure, to learn about communication, our physical capacities - the list is endless.
Play allows parents and professionals to focus on the child's abilities. It reinforces the positives and in doing so sends the message to all involved that the child is first and the impairment only part of their individual make-up. Parents have a key role in developing play opportunities since they are in position to bring in aids and adapted toys from home and have been working on ways to include their child.
"For the private nursery, I take in most of Arron's equipment - chair, switch toys and other specific toys. Staff are creative and make mobiles, etc, but generally, he is included in most of the activities with use of his chair (Jenx whale) or the Bumbo [a make of chair]". - says a parent of three-year-old at mainstream nursery and playgroup.
- Children with hemiplegia need the fun of play like their peers.
- You do not need to buy expensive equipment - adapt play to meet the child's abilities.
- It is the play interactions between staff and children that matter.
- Make the child a part of play.
- Follow the lead of the child you want to include - observe what activities the child enjoys.
- Find ways to stabilise toys to enable play e.g. with Velcro or non-slip mats.
- Use play to encourage children to recognise differences in all of us.
The child should:
- Sit squarely at the table, with their affected arm on table, to keep the spine straight.
- Have adequate space for affected arm.
- Have unrestricted movement of their stronger arm, e.g. in group play try not to place a left handed child with hemiplegia close to a right handed child.
- Stand at an easel or sand tray facing forwards, not sideways, with both feet firmly on the floor.
- Have computer screens at eye level.
- Learn to draw, scribble and begin to form words on a well-stabilised vertical surface, or later on an angled surface.
In more formal activities the nursery worker or supporter should sit facing the child.
If the child is easily distracted, or may be showing signs of a visual perception problem:
- Surfaces need to provide a clear background for writing, drawing etc.
- White boards are better than black or green, and plain table tops might be more effective covered in off-white paper.
- Display boards should be in the child's direct line of vision with the minimum opportunity for distraction, or adjusted for the child's restricted vision/field defects.
- In group play the child should be seated in the front or the middle of the group.
- For table play and other practical activities the teacher/support assistant should sit alongside so that they have the same angle of vision as the child.
- For children where group or individual sustained play is difficult, it is helpful to work face to face so that the child can see facial expressions, check eye gaze and eye movements
Left to themselves, younger children with hemiplegia often tend to ignore their weak side and need to be reminded from time to time to bring it into their activities. Doing things like dressing or naming parts of the body in front of a mirror can help them be more aware of both sides of their body.
Sitting on the floor can be more of a problem for some children. Parents, carers and therapists should be able to advise on the best position for the child.
See our parent guide on holidays, play and leisure [PDF]
Early Years Alliance is a community pre-schools support and campaigning organisation. www.pre-school.org.uk
Bag Books is a charity that produces multi-sensory stories for people with learning disabilities.
Portage is a home visiting educational service for pre-school children with additional support needs and their families. Families have found Portage invaluable in supporting inclusion in early years settings.
Activities and games
A lot of the equipment needed by children with hemiplegia, such as chunky pencils and crayons, non-slip mats and left-handed scissors, is generally available in nursery and pre-school settings. Specialist equipment that might be useful includes magnetic boards or clipboards for anchoring paper (or use Blu-tack), an angled table top and a chair that supports the child in the correct forward-facing position.
Children with hemiplegia can join in all the usual games and activities that form part of nursery and pre-school, although things requiring two hands or balancing on one leg may be difficult for them. They may also need a little more space in group activities, so as not to feel crowded.
Pre-school activities designed to develop skills such as counting, letter recognition, matching and sequencing and co-ordination are particularly useful to children with hemiplegia, although they may need to have tasks broken down as well as some extra help.
Many children with hemiplegia have specific learning difficulties with reading, spelling or maths. These are not easy to identify at this stage, but it is worth looking out for warning signs such as difficulties with:
- Puzzles or matching games.
- Building blocks.
- Drawing age appropriate figures and objects.
- Pre-letter formation.
- Getting their bearings when moving around the nursery or room.
These are all indicators of possible visual spatial problems, and professional help should be sought.
To help children who have problems with puzzles, try using shapes to stick onto Velcro - e.g. parts of a face, car, house etc. that they can join together to make a whole.
To help children who have problems with spacing, use sticky labels to construct bar charts when recording their play activities or making pictures or charts
Emotional and behavioural problems
Some of the following are common in all children of nursery age, but in children with hemiplegia they may be markers for more serious difficulties later on:
- Difficulty in settling down.
- Restlessness or fidgeting.
- Poor memory.
- Excessive shyness or clinginess.
- Difficulties with making and keeping friends.
Any of the above should of course be discussed with the parents or carers, and advice sought from any of the professionals working with the family or nursery/pre-school.
All children find starting nursery or reception class tiring, but children with hemiplegia find it more tiring than most, constantly needing to think about what they are doing and how they are going to do it.
A partnership approach
By the time children with hemiplegia come to nursery or pre-school, their parents or carers will have been working closely with therapists to minimise their difficulties and develop self-help skills. If children are to build on these skills it is important that this be reinforced at nursery or pre-school. A partnership approach between parents and carers, therapists and teachers is the surest way to maximise the child's abilities.