In this section

Helping children in pre-school

16 mins read

How to help a child with hemiplegia in pre-school settings like nurseries, children’s centres, playgroups and crèches. Much of this information will also apply to children with other additional needs in pre-school.

In this article

Top tips for staff working in early years 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 pre-school setting

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

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:

What to expect from children with hemiplegia

At this age 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 at this age. 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 staff are ideally placed to pick up early signs of potential problem areas.

Find out about hemiplegia and its symptoms.

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.

Physical practicalities

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!

It’s important to remember that every child is unique, and you – working in partnership with parents and professionals – 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 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

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!”

Eating and mealtimes

Staff may be the first to encourage a child to feed himself or to make choices about food and drinks. 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.

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.

“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.” 

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. 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.

Communication

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

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.

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.

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.

“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]”. 

Getting started

You do not need expensive equipment – adapt play to meet the child’s abilities. It is the play interactions between staff and children that matters. Here are some tips:

  • 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, for example with Velcro or non-slip mats.
  • Use play to encourage children to recognise differences in all of us.

Ensure the child:

  • Sits squarely at the table, with their affected arm on the table, to keep the spine straight.
  • Has adequate space for the affected arm.
  • Has 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.
  • Stands at an easel or sand tray facing forwards, not sideways, with both feet firmly on the floor.
  • Has computer screens at eye level.
  • Learns 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 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.

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.

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.

What can help play and learning

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.

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

Emotional and behavioural issues

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 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.

Take a look at our information about challenging behaviour

Check out our information about emotions and behaviour in children with hemiplegia

Moving into primary school

We’ve got lots of information about moving schools, for example from nursery to primary school which may be helpful.