Hemiplegia is a paralysis of one side of the body as a result of an injury or abnormality in brain development on the opposite side. There may be weakness or lack of control in an arm or leg or both and often balance is affected. The condition may be complicated by epilepsy and the effects of medication and some children suffer impairments in speech and visual processing. As the children develop, some functions can be taken over by undamaged parts of the brain so that motor impairment is minimised, but specific learning difficulties and behavioural problems are quite common. The children often tire easily and friendships can also be a problem.

There is huge variation in the severity of problems associated with hemiplegia, depending on the extent of the damage, and sometimes it causes relatively few difficulties. Children often present towards the severe end of the sensory integration continuum, however, with clear immaturities in most areas of sensory integration. This is partly because movement is vital to the development of mature systems in sensory integration, and bi-lateral movement in these children is impaired; partly because the damage makes it difficult to simultaneously access information on both sides of the brain, which is essential for efficient brain integration. The condition is complicated by the degree of hypersensitivity they suffer. The physical impairment and processing difficulties they have to deal with in the classroom can put them under a great deal of pressure and if they also have to deal with a huge sensory overload their coping strategies can be overwhelmed.

Brain integration difficulties are nearly always a major factor in hemiplegia, and they are likely to lead to difficulties in comprehension. This affects schoolwork, but also social comprehension which is important for friendships. They may lack the ability to process all the information required for the ‘right’ response’ in social interaction and find it difficult to adopt a flexible approach. Often they are happier with younger children or adults, who can easily make allowances. Stamina is also a very common problem, not only in terms of keeping up physically with the group, but in managing to finish off pieces of work in class and coping with homework after a day which is more tiring for them than it is for other children. Behavioural outbursts are often simply the result of exhaustion, but there are also self-esteem issues as a result of perceived failure or being side-lined by the group due to their physical limitations or difficulties with interaction.

Suggested action

Children with hemiplegia generally have access to occupational therapy and physiotherapy services and speech and language therapy if appropriate. The sensory integration issues and their impact on classroom performance are rarely fully explored, however, and there can be insufficient understanding of the child’s issues. Use the website to investigate the totality of the problem – the better the child is understood the more they can be helped and the less stress they will suffer. Stress has a major impact on performance and development.

Case histories

THEO

Presenting problems

Theo had left-sided hemiplegia. The right side of his brain was slightly small than it should be, and not developed in the same detail. His left arm was not used at all when he was very young and although he had since developed some function in it there were real problems with motor control. His left leg was not so badly affected, but there were problems with the tendons and a slight pronation. It caused him to be rather clumsy, with poor balance and he found physical activity quite tiring. He had suffered epileptic fits in the past and was still on medication which seemed to be associated with moodiness and some difficult behaviour sometimes. He had occasional asthma attacks, mainly linked to chesty colds, and a sensitivity to pollen. He often had a runny nose but he seemed curiously unaware of the sensation.

Theo was an anxious child and a poor sleeper. He found it hard to get to sleep and often woke later in the night. He was finding maths quite challenging, there were difficulties with reading and it was hard for him to focus his attention. He also had problems with expressive language. Difficulties with sentence structure, grammar and tenses became noticeable at about seven years old. There were also some issues with behaviour and social adjustment and he found it hard to make friends.

Assessment

Theo was assessed at the age of eleven. Standardised computer tests suggested a child of below average IQ, with a poor visual spatial memory, which would relate to his particular difficulties with maths concepts.  His reading was several years behind his age. He was slow and under-confident, losing his place and struggling to get to the end of each sentence, with a number of substitution errors where he had not quite seen the word accurately enough. Comprehension was nearly five years behind his age, and he was about to transfer to secondary school. His memory skills were also poor, nearly four years behind his age.

The assessment revealed difficulties in most aspects of sensory development and integration. His muscle tone was very poor, there were hypersensitivities in the senses of smell and sight and his  balance and body-in-space awareness were poorly developed. His sense of touch was oversensitive in some areas and under-sensitive in others, which is why he recoiled from some tactile sensations on his fingers, but was unaware of his runny nose. His eyes could not follow a moving object smoothly in all planes and he had a very slow speed of processing on the auditory processing which resulted in very poor sound discrimination ability. All this would result in an inaccurate perception of the environment, sensory overload and a poor base on which to build the higher levels of sensory integration.

Theo’s differentiation was immature, so there were a lot of overflow movements when he was concentrating (he would scratch and rock when he was reading ), he tended to knock things over at the table and would find it hard to turn off obsessive-compulsive thoughts and actions. His laterality was also poorly established in spite of the fact that the left side of his brain was much more developed than the right. He had no eye-dominance at near-point, although he favoured his right eye in the distance. His motor integration was particularly poor, so tasks such as tying shoelaces, pulling on trousers, getting his arms into sleeves etc. were hard, and there were particular difficulties with organisational skills and the concept of consequences. Fine motor skills were very poorly developed and his speed of auditory integration was slow.

Progress

After two years Theo had responded to the programme very well. His working memory was now measured  as age appropriate. His balance on his good leg was much better and his speed of auditory processing had normalised. His IQ had increased from the 17th centile to the 70th centile – by that measure only 30 children in a hundred were brighter than him. His comprehension had improved by more than six years and was now ahead of his age. He was doing very well in Spanish too. His visual processing had improved significantly but his two eyes were still not working well together and eye dominance was not fully established so he was still making a large number of substitution errors when he was reading.

At school Theo had been picked for the cross-country team, having finished in the top six in his class in their weekly one-mile run. He was also able to swim further and faster - he had joined a swimming club and achieved his one mile badge. His stamina and energy levels were much better in general – he was much more lively first thing in the morning and no longer dipped towards the end of the week. There had been no more epileptic fits, and his medication had been reduced. Academically his teachers said he was doing fine.