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Early years education

Early years education is important for all children as the foundation for their future development, not only cognitively but also socially. Preschool and daycare providers therefore have a pivotal role to play in a child’s life. This is especially true for any child with additional needs.

Sending my boys to playschool was very emotional as they both were not walking. But having said that, mixing with “normal” children has done the boys confidence a wonder of good. Within 3 weeks of attending playschool, their speech progressed and they both started walking!

What is hemiplegia?

Childhood hemiplegia is a condition affecting one side of the child’s body (Greek `hemi’ = half). We talk about a right or left hemiplegia, depending on the side affected. It is caused by damage to some part of the brain, which may happen before, during or soon after birth, when it is known as congenital hemiplegia, or later, in which case it is called acquired hemiplegia.

What are the main effects?

The most obvious result of childhood hemiplegia is a weakness or stiffness with poor hand function and mobility on the affected side. It is difficult to generalise further: hemiplegia affects each child differently. The physical effects may be very obvious, or so slight that they only show when he or she is attempting specific activities.
Some children with hemiplegia have additional medical problems such as epilepsy and visual field defects. (The two national organisations for people with epilepsy, BEA and NSE, produce information leaflets).

What to expect from children with hemiplegia?

At this age it is mainly their physical differences which 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.

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. 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 (see below for example).

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.

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

Moving around

Although most children with hemiplegia have good mobility by the time they come to nursery, poor balance means that they fall over more easily, so care should be taken to avoid jostling in busy areas.

Dressing

It helps if the child wears clothes that are easy to manage e.g. jogging bottoms rather than dungarees, tops that go over the head rather than buttons or zips, shoes with Velcro rather than laces.

Eating and drinking

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.

Helping the child learn through play

The child should:

  • sit squarely at table, with affected arm on table, to keep spine straight
  • have adequate space for affected arm
  • have unrestricted movement of stronger arm i.e. in group play try not to place a left handed child with hemiplegia close to a right handed child
  • in more formal activities the nursery worker or supporter should sit facing the child
  • stand at 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

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, plain tabletops 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 to enable them to have the same angle of vision as the child.
  • however, 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.

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 tabletop 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.

Suggestion

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
  • distractibility
  • restlessness or fidgeting
  • poor memory
  • excessive shyness or clinginess
  • difficulties with making and keeping friends
  • anxiety
  • irritability
  • aggressiveness

Any of the above should of course be discussed with the parents/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/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/carers, therapists and teachers is the surest way to maximise the child’s abilities.

Also available from HemiHelp:

Guidelines for teachers: The child with hemiplegia in Primary education

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