By Stanley I. Greenspan, M.D.

A five-year-old boy in my pre-K class has cerebral palsy. His right side is weaker than his left, and his right arm is rigid. He has a brace for his right leg, and he walks in a kind of bumpy way. He can't run, and his speech is sometimes unclear. He has trouble drawing and writing. Since he's getting physical, speech, and occupational therapy, these physical handicaps don't worry me as much as his social limitations. He's a sweet boy who sometimes looks a bit sad. How can I help him make friends and feel he belongs?

I'm glad that your first priority for this child is his social and emotional development. Children with physical challenges often have difficulty with relationships because of their physical limitations. In fact, moving through each stage of development, including social, emotional, and intellectual as well as physical development, is much harder for them — but still do-able. Let's look at some of the skills children must acquire as they grow and see how learning them can present unique challenges for children with physical limitations.

Skills and Challenges

Infants need to learn how to focus and attend to things apart from themselves. That involves coordinating what a baby sees with what he hears; naturally, he wants to look toward the voice of Mommy. But that might require turning his head, which can be hard for a child with low muscle tone or a weakness or rigidity on one side. So learning to focus and pay attention is the first challenge.

Then, babies must learn to engage another person. It's important not only to look and listen, but to respond with great big smiles and enticing glances to woo parents into a loving relationship. That can be even more difficult for a child who can't turn, move easily, or reach up with her arms in efforts to get a hug, or move her face into big smiles.

Next, babies must learn to act purposefully. This involves exchanging emotional expressions and interactions — taking toys that are offered and handing them back, all while making gleeful sounds. But that is difficult too, if you can't move your arms or grasp something offered to you.

Children must also be able to perform a sequence of activities in order to problem-solve — for example, taking Mommy by the hand, walking her to the toy area, pointing to the toy you want, and climbing up on Mommy's lap to reach it. Obviously, if you have severe motor problems, all those actions are difficult.

Using ideas creatively is another skill children must master. To do this, they have to be able to engage in pretend play, which might include picking up the doll, talking to it, and organizing a tea party. All of this involves complicated motor behavior.

Finally, children need to learn to connect ideas. Some of the ways children do this are by talking with one another and by joining in games such as musical chairs or ring around the rosy. Obviously, it's difficult to get involved in such activities when you have speech and motor difficulties.

You can see that motor skills play a big part in the overall development of children and that the challenges for a child with motor delays go way beyond having a hard time writing, running, and jumping.

Focus on Abilities

Here is the good news: Once we know what our goals for a child should be, we can draw on his many capabilities to help him achieve those goals. The motor system is not the only capability children have, and we can often take advantage of even limited motor ability. Let's take a child like the one in your class, who has weaknesses on one side of his body but has control over some muscles. He has one arm that's working well, so he can reach for things and show you what he wants. Even without a good, functioning arm, the child can convey ideas verbally or with signals. So he can learn to be purposeful. It's vital to use all of the child's operating senses and abilities, including language skills and the ability to see, smell, hear, and move certain body parts. Like many others in his situation, this little boy apparently does not feel that he can make things happen. That could lead him to regress or to escape into his own private world when the going gets rough.

A different child in his situation might have temper tantrums. But if you can work around the limitations of his muscles and create situations that allow him to explore his own assertiveness, you will be helping him enormously. You might pair him up with another carefully chosen child, and find activities in which the boy with motor problems can be an assertive play partner. Although his speech is not always clear, he does have verbal skills.

Now, suppose you suspect that he is gifted musically. Draw on that. You know he can't dance, but he can use one arm very well. So he can hold a baton and lead other children who are playing different instruments. He is assertive and making things happen. You, the teacher, have engineered it, evened the playing field. The key is to create social games where this child does not have to be just a passive follower.

Encourage Involvement

Another thing you might do to encourage involvement is use a tape recorder for children to "write" stories. The physically challenged child can get pleasure from creating along with his peers. Outdoors, if this child can't participate in a kickball game, you might encourage him to play with others in the sandbox. Encourage the children there to create a drama with toys, using their voices rather than their bodies. Here again you are helping the physically challenged child practice the skills he does have. Remember to always praise his efforts. The harder the task, the smaller the steps, and the greater the external rewards should be.

Caution in Careful Doses

Finally, a word about being overly cautious: Teachers and parents should not be inhibited about their expectations of a child with physical challenges. In fact, they should capitalize on every opportunity that gives the child a sense of accomplishment.

Teachers, parents, and outside experts all have the same goal — to enable the child to become a creative, assertive, warm, friendly and social young person.

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Stanley I. Greenspan, M.D., the author of The Child With Special Needs and, with Nancy Breslau Lewis, Building Healthy Minds, is a clinical professor of psychiatry, behavioral sciences, and pediatrics at the George Washington University Medical School.