Helping children with hemiplegia at nursery and school

29 mins read

How to help children with hemiplegia at nursery and school. Much of this information will also apply to children with other additional needs in pre-school.

In this article

What is Hemiplegia?

Watch our short animation to learn more about what causes hemiplegia, how it affects children, and what treatments and other support are available.

Top tips for staff working in early years and primary settings

  1. Get to know more about hemiplegia and how it can affect a child. Children may also have other challenges like visual perceptual problems and emotional and behavioural issues.
  2. Break down tasks and give some extra help. 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, if they are broken down.
  3. Give extra time. Children with hemiplegia constantly have to think about what they are doing and how they are going to do it. They can find time at nursery more tiring than their peers, so give extra time for tasks.
  4. Resist the temptation to do too much for a child with hemiplegia.  Encourage the child to do things for themselves, even it it takes longer, and give lots of praise for every achievement, however small.
  5. Encourage children to bring their weaker side into activities by reminding them to be as two-handed as possible, for example, when eating or drinking. Children with hemiplegia tend to ignore their weak side.
  6. Encourage hand/eye co-ordination by asking children to reach for things, don’t just give them to them.
  7. Give a child with hemiplegia a little more space in group activities so they don’t feel too crowded and make sure they have unrestricted movement of their stronger arm. For example, in group play try not to place a left handed child with hemiplegia close to a right handed child.
  8. Identify issues early for successful intervention. Many children with hemiplegia have specific difficulties with literacy and numeracy. Look for signs like problems with puzzles and matching games, building blocks, drawing age-appropriate figures, and getting their bearings.
  9. Work in partnership with parents. 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. It’s important that this is reinforced in early years settings. A partnership approach between parents and carers, therapists and teachers is the best way to maximise a child’s abilities.

Creating an inclusive school setting

At Alex’s primary the head talked to the whole school before he arrived and that was a great help.”

Including disabled children in your setting is a case of extending ordinary good practice and recognising that all children have interests, ideas and aptitudes.

In a successful inclusive education setting 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:

The earlier we can start working on diversity the better . So in drama, make the other children feel what it means not to be able to use one hand to, for example, button their shirt.

What can help

Ways of helping a child with hemiplegia to feel included are to:

  • Encourage children to talk about themselves in class, for example at Circle Time, so that a child with hemiplegia might, for example, tell classmates why he/she has to wear a splint, while other children might talk about wearing glasses or having braces on their teeth.
  • use a circle of friends or buddy system
  • have an older pupil as a mentor, looking out for the child in the dining room and playground
  • give the child a regular task in the classroom which will boost his or her self esteem, for example watering the plants.

I met with the special needs coordinator at the school well before L started. I got her preschool care providers involved in this meeting so the school were fully aware of the issues and how they could be dealt with.”

What to expect from children with hemiplegia

Although most children with hemiplegia have good mobility by the time they come to nursery, poor balance means that they may fall over more easily, so care should be taken to avoid jostling in busy areas. A child with hemiplegia should be able to participate fully in most classroom activities, although they will need some help with certain things. It’s important to encourage them to make use of their affected side as much as possible.

Parent carers and therapists will have been working with the child to make them as ‘two-sided’ as possible and it is important that this is reinforced at school. Likewise, you should keep parents informed of what skills you are encouraging their child to develop at school, so it can be reinforced at home.

Placing a friend on their weaker side may encourage awareness of that side. If the child is working with an adult, make sure the adult varies the side they sit next to the child so they aren’t always sitting on either the child’s dominant or affected side.

In the early years it is mainly 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. These include:

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. Pre-school and primary school staff are ideally placed to pick up early signs of potential problem areas.

Find out about hemiplegia and its symptoms.

Emotional and behavioural issues

My child is normally sweet natured but suffers outbursts. The triggers seemed to be tiredness, anxiety, change of routine, too many people in the house, any suspicion of criticism or belittling.”

Children with hemiplegia are likely to go through a period of significant emotional and behavioural problems at some point in their childhood. Studies have shown that over half of children with hemiplegia will have some of these problems. They can take various forms and may in some cases require specialist advice. Emotional and behavioural problems can include:

  • Excessive shyness or clinginess
  • Difficulties with making and/or keeping friends
  • Difficulty in settling down
  • Distractibility, restlessness or fidgeting.
  • Poor memory.
  • Excessive anxiety.
  • Fear of failure resulting in unwillingness to do tasks
  • Irratability or aggressiveness.

You can discuss any of the abovewith the parents or carers, and seek advice from any of the practitioners working with the family or your setting.

Bear in mind also that for children with hemiplegia school is much more tiring than for the average pupil. As the school day goes on, fatigue may have an effect on all activities, and may trigger tears or irritability. It would be useful for the child to have somewhere to go for a short rest if they show signs of being tired.

Physical practicalities

Children with hemiplegia are just like all other children and simple solutions are often the most effective. You might be tempted to overprotect a disabled child; it is easy to make assumptions about capabilities. But children with hemiplegia are usually much more robust than we think!

Every child is unique, and you – working in partnership with parents and practitioners – will find ways of dealing with 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 issue, 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.
  • Placing a friend on the weak side may encourage awareness of that side. If the child is working with an adult, ensure the adult varies their supporting position so they do not always sit on either the dominant or affected side.

Encouraging independence

Many everyday tasks, such as eating, dressing and going to the toilet are more difficult if you have only limited use of one hand. Children with hemiplegia may need more help and take more time to do some activities.

It can be helpful to break down each task into stages. For example if a child struggles to pull up their trousers:

  1. Pull trousers up nearly to waist and support child to use both hands to get the final part done
  2. Trousers over bottom and let child pull rest of way
  3. Trousers to thighs and then child pulls rest of way
  4. Child pulls up trousers by him/herself.

At the same time, teachers and helpers should resist the temptation to do too much for the child. The aim should be to encourage independence.

Handling a child with hemiplegia

The suggestions below are about how you lift, carry, hold and position a child and learn to control any muscle stiffness or uncontrolled muscle movements. 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. The best way to handle a baby or young child depends on age, type of hemiplegia, and how the body is affected.

  • Try not to move the child suddenly or jerkily. The muscles may need time to respond to changes in position.
  • Don’t force movements. Some children’s muscles tense (spasm). Let muscles tense and relax in their own time.
  • Give the child as much support as they need. Fear can make muscles spasm worse, so when you are handling them, be careful not to give them more support than they need.
  • Make sure they spend time in different positions – whatever their size or level of impairment.
  • Try to position the child so they can see what is going on around them.
  • Make sure seating is properly fitting and supportive. Many physically disabled children are greatly advantaged by good 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.
  • Get help from practitioners if needed. Physiotherapists and occupational therapists 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 them develop the best possible control over their 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!”

Getting around school

Limited use of one arm and hand and possibly poor balance and co-ordination can cause difficulties in various areas like opening doors, climbing stairs, carrying a heavy schoolbag or sports equipment, or carrying a lunch tray. Suggestions:

  • Use of a locker.
  • Extra time to collect books/get up and down stairs between classes.
  • Help from other children. If children are paired with a friend or buddy this should be monitored to make sure both children are happy with the arrangement. It is also a good idea to do a risk assessment if a child is helping another child carry books
  • Put cloakroom peg at the beginning of the line and at an appropriate height to avoid the child being overcrowded.
  • Some students have visuo-spatial problems and may have initial difficulties finding their way around school. Clear signposting of rooms, laboratories, and so on (with teachers’ names) will help them.

Seating

Students should:

  • Face the teacher.
  • Face the board or demonstration area.
  • Be away from the main aisle or door, to minimise distraction.
  • Have adequate space for the affected arm.
  • Have unrestricted movement of the dominant arm.

Writing and drawing

Some children with congenital hemiplegia may never be able to use their affected hand. If they are lucky, their dominant hand will be their preferred writing hand. Issues arise if the dominant hand is the left one and the child would have been naturally right-handed. Children learning to write with their affected left hand tend to have more difficulties than non-disabled left-handers.

Children with hemi may also struggle with stabilising paper, drawing graphs, diagrams, etc, setting out work, and with poor co-ordination affecting handwriting. Suggestions:

  • A4 is easier to manage than A3.
  • Using a keyboard can ease problems with handwriting and setting out of work. Make sure the child has enough space to work and place their affected hand flat on the table.
  • Blobs of ‘blu-tack’ can help anchor paper. However, some children find it easier to work on paper which is at an angle to the end of the desk. Try using a clipboard which the child can adjust to the angle they require and then hold down with their affected arm.
  • Loose leaf notebooks or sheets attached to clipboards may be easier to manage than exercise books.
  • A magnetic board, used with rulers and geometry instruments also backed with magnetic strips, can help with drawing graphs, diagrams etc. Pre-prepared diagrams and graphs may also be helpful. If the child has visual spatial difficulties, consistent colour coding of columns and other spaces specific aspects of maths will help.
  • Tasks may need to be broken down into more manageable units and extra time may be needed.

Children with acquired hemiplegia

Children with acquired hemiplegia, for example child stroke patients, may regain the use of their preferred writing hand with luck and good therapy (if that is the hand affected by the stroke). It may be counterproductive to retrain their non-affected hand if they lose their preferred writing hand even temporarily. This may result in real problems later in life. Trying to write with their affected hand – starting with just name writing – is perhaps the best therapy and perhaps the easiest way to regain usage of the affected hand. This is not a hard and fast rule.

Computers

Many of the issues experienced by children with hemiplegia at school may be alleviated by the use of a computer, for example, poor handwriting skills. Often a few simple tweaks and adaptations can make the system more useable for the child. Using a keyboard may:

  • Help students with poor handwriting skills.
  • Help develop the ability to present work effectively.
  • Help develop personal organisational skills.
  • Help dyslexic students correct spelling.

Practical work

The student may feel more self-conscious or clumsy during practical work and may need encouragement to participate. They may have issues with model making, conducting experiments, cooker, technology, and safety factors, as the affected limb may have reduced sensitivity. Suggestions:

  • Pairing with another student.
  • Modification of equipment.
  • Extra time to complete tasks.

Music

Many instruments can be played with one hand, or hands of differing strengths, and the pleasure of music making may encourage the child to make more use of the affected hand. See our information on musical instruments for children wtih hemiplegia.

“I started playing the recorder and the flute at school. It really helped me to become aware of my affected hand as I had to use it more to be able to play more challenging music. When I first started learning I had little movement in my right fingers but now I am able to play up to Grade 8 pieces and I am in a youth band that I love.

Going to the toilet

Toilet training may be more difficult for a child with hemiplegia. For example, it may be hard for them to relax or use their muscles to empty their bowels. Continence can sometimes be a problem, too. However unless told otherwise, delay in toilet training is not usually a medical issue, but a lack of opportunity or experience. It may be helpful to establish a toilet training routine – talk to parents about how they manage at home. A therapist or health visitor can give help and support.

Find out more about potty and toilet training.

Dressing

Always put clothes on the most affected side of the body first. If a child’s legs are bent before putting on socks and shoes it may help ease any stiffness in the ankles and feet, and 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. We have advice for parents on dressing a child with hemiplegia you may useful.

It helps if the child wears clothes that use velcro and elastic rather than buttons and zips. There are specialist suppliers like our online Fledglings shop who provide clothes with the needs of disabled children in mind.

Eating and mealtimes

Staff may be the first to encourage a child to feed himself or to make choices about food and drinks (if in pre-school). Some children with hemiplegia cannot suck and swallow and chew easily, so eating may be messy. It may also take longer. If a child has difficulties when eating a health visitor can advise, and a speech and language therapist can give specialist help and support.

Try to encourage children to be as two-handed as possible 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.

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.

A Year 6 pupil helps A in the dining area with opening crisp packets and yoghurt pots etc .”

Brushing teeth

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 their teeth after every meal and cut down on sugary food and drinks.

Find out more about dental care for disabled children.

A note about nutrition

Children with hemiplegia use a lot of energy just getting through the day. Re-fuelling stops should be allowed to have snacks throughout the school day and if necessary specialist advice on healthy eating and nutrition be sought. The child’s parents will know what foods a child can eat and should avoid.

Difficulties with learning

Because of their physical limitations, most students with hemiplegia experience some difficulty and frustration at school and may need a little more time and attention to achieve their full potential.

Some young people with hemiplegia have general or specific learning difficulties which may be slight or severe, and which can be more frustrating and disabling than their obvious physical ones. Because of this, they may have particular difficulties with literacy and numeracy.

Teachers and parents need to be aware how tiring problem solving is for children with hemiplegia. Children with hemi need to constantly think about what they are doing and how they will do it.

Some children with visual perceptual issues may need to start from scratch every time they encounter the same problem. This can also result in emotional and behavioural problems, as the children tend to avoid tasks where they experience difficulty compared to their classmates, so gain no practical experience to build on. This can lead to a sense of frustration and failure.

Short concentration span

Non-disabled children make cognitive maps all the time to decide what information to keep and what to discard to avoid overloading the brain. Children with hemi seem to have difficulty deciding what to keep and what to discard. Sometimes they attend to minute peripheral details rather than discarding irrelevant information, and then miss the main points of a task. They may also suffer with difficulty settling down to tasks, frequent lapses of attention, and a tendency to be easily distracted. Suggestions:

  • Seating: sit the child square on to the board or face to face, to avoid having to turn toward stimuli. In group work, sit the child in the middle or front of the group.
  • Break down tasks into smaller units.
  • Focus on short sessions of concentrated effort.

Short term memory problems

Children with hemiplegia may not retain information or instructions. They may also have difficulty sequencing a series of instructions or objectives.

Giving the child simple repetitive tasks, such as watering plants on a regular basis or other classroom chores, can help them develop information retention skills. Teaching memory skills can also be helpful, for example simple games like ‘I packed my bag‘. Other helpful strategies are making lists and keeping a diary. Suggestions:

  • Give instructions one at a time, repeating as necessary, then ask the child to repeat the instructions back to you.
  • Write instructions down or use visual clues/prompts. If possible, do both as they will reinforce each other.
  • Use a visual timetable or interactive whiteboard for prompting and keep this near the child so that they know what they are doing and have a context for the task
  • Give clear, written goals for all tasks, to help students to develop personal organisational skills.
  • Encourage students to draw up a work plan for each task.

Many of the learning problems outlined above can be alleviated by the use of a computer. We have advice on how to make keyboard adaptations which will help children with hemi.

Lily does well with structure and routine so the teacher has implemented a picture schedule so that Lily knows what she will be doing that day.”

Fatigue

One of the hidden effects of hemiplegia is mental fatigue, also called ‘neuro’ or ‘cognitive’ fatigue.

Following the injury which causes hemiplegia, the brain re-wires through a process called neuroplasticity. This is an amazing adaptation but it means that the brain works harder to carry out the same actions or thought processes.

It is estimated that a child with hemi uses three times as much energy as their peers. Being at school is just genuinely more tiring for a child with hemi. Even with skills and aptitude, they may need longer to complete their work. If children worry about not keeping up, that will also tire them emotionally.

“After a day at school, M is often exhausted and very tearful. She is usually asleep by 6.30 pm, and I have to wake her at 7 am. We rarely walk to or from school because M becomes extremely overtired.

Communication

Disabled children may use different methods of communicating, such as signs, symbols, behaviour, hand / eye-pointing, facial expression. They still express the same feelings, but in a modified manner, such as going into extension spasm with excitement.

  • 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.

“Communication falls into the same category as food, drink and shelter – it is essential for life, and without it life becomes worthless.”

Augmentative and alternative communication

Alternative and augmentative communication, also known as alternative and assistive communication (AAC) is used to describe all the different ways that help people with disabilities communicate. AAC aids range from printed picture symbols, to high-tech tools, such as voice recognition equipment.

Resources to help:

  • Communication Matters supports people of all ages who find communication difficult because they have little or no clear speech. Information on AAC to supplement the more usual methods of speech and writing.
  • 1Voice Communicating Together is run by parents for users of low-tech and electronic communication aids and it offers information and support.
  • AAC Scotland has a range of practical AAC resources.
  • Ace Centre has free resources and information on getting an assessment for AACs.
  • Speech and Language UK has in-depth information, advice and support about communication aids and equipment which may be available to help.
  • AbilityNet gives advice on using computers through assessments, workshops and courses. It also has an extensive list of communication aid assessment centre / services.

    Find out more about aids and equipment that may be available.

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.”

Children with hemiplegia need the fun of play like their peers. Play allows parents and practitioners 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. It is the play interactions between staff and children that matters.

Talk to parents about how they play with their child. 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. 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.

To help children who have problems with puzzles, try using shapes to stick onto Velcro, for example parts of a face, car, house and so on, 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

If more help is needed

If the child is easily distracted, or may be showing signs of a visual perception problem:

  • Make sure surfaces provide a clear background for writing, drawing and so on.
  • Use white boards – they are better than black or green, and plain table tops may be more effective covered in off-white paper.
  • Put display boards in the child’s direct line of vision with the minimum opportunity for distraction. Or adjust them for the child’s restricted vision/field defects.
  • For group play, sit the child in the front or the middle of the group.
  • For table play and other practical activities, sit so that you have the same angle of vision as the child.
  • If group or individual sustained play is difficult for the child, work face-to-face so that the child can see your facial expressions, and 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.

Play resources

Our information on holidays, play and leisure has ideas of accessible games and activities including where to find toys and sensory equipment.

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.

“For the 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]”. 

Activities and games

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.

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.

PE and sport

Give them opportunities to do things even if you know that they will only achieve a little. We took S to a climbing wall when he was about six because he desperately wanted to have a go. The instructor was great. He got about three feet off the ground but thought it was marvellous and still talks about the experience.

PE can play an important role in helping children with hemiplegia increase their dexterity and range of movement, and improve their balance and spatial/perceptual abilities. Pupils with hemiplegia should be allowed to wear trainers or orthopaedic sports boots for PE rather than plimsolls, which may not give enough support to their feet. Physical differences will be the most obvious when undertaking PE and sports activities and it can be very demoralising to always finish or be picked last. In group activities, a child with hemiplegia may find it easier to be in a smaller group.

  • Be flexible. Try allowing head starts, or developing underarm serving techniques
  • Be imaginative. Encourage the child to try new sports, for example fencing, sailing, contact sports. See our directory of Sports Bodies.
  • Be patient. Allow more time for activities, and also for undressing/dressing. Remember, that the child has to expend more energy than his/her classmates to achieve the same goals, and may tire easily.
  • Use beanbags (easier to catch), or foam balls or balls with a textured surface, may help gripping and releasing skills
  • Grips are available to help hold bats and racquets.

Take a look at our sports and fitness page for links to agencies and associations that can support children with disabilities including hemiplegia.

If they can’t take part in a particular sport try and include them in some way. My son cannot play rugby but organises all the water bottles for the team.

Cycling

He likes to play on his go-kart, scooter and bicycle. He loves swimming.”

There is no reason why children with hemiplegia should not take part in cycle proficiency training. The Department for Transport funds Bikeability cycle training for schools. Children will be given extra training to reach the required level if necessary.

A safety concern is signaling, which, depending on which way they are turning, involves either steering with their affected hand while indicating with their stronger hand or using the affected hand to indicate. If turning right at a busy junction it may be better to dismount and walk across. If the child is taking part in a training scheme this is something to discuss with the instructor.

Friendships and relationships

I made lots of friends at primary school and when we went up to secondary they really looked out for me and stopped anyone bullying me.

Having friends is vital for our self-esteem as we grow up. Some childrenwith hemiplegia have similar difficulties to those with autism spectrum disorders in reading other people’s reactions and feelings, a common enough aspect of hemiplegia that affects the ability to make and keep friends.

Although teasing, bullying and being ignored can happen to any child, with or without a disability, children at this age are generally accepting of difference, and this is a good time for forming friendships which may carry a child through to the more tricky secondary school stage.

Our webpage about friendships includes helpful tips to encourage children to make friends.

Our bullying webpage has information about what parents and schools can do to deal with bullying.

He has good friends, he’s grown up with some of them, they’re always looking out for him.”

Visit our practitioners hub

Find out more about our offer for practitioners

Go to hub