These case studies are based on children at Fortune Park and Rosedale Early Years Centres in Islington, London. These are both mainstream nurseries, funded through education and social services by Islington Council. They take children from nought to five years, including extended day and extended year provision.
Fortune Park has places for 65 children, with six places for children with severe and complex special needs, which are funded by the authority.
Rosedale has 52 children, with no places set aside for children with severe and complex special needs. Both centres are well supported by the borough's inclusion team and a range of specialist services provided by the health authority, with access to educational psychologists.
However, it is the staff's positive attitude towards children's diversity and their willingness to change the curriculum to the needs of a range of children that is the key to successful inclusion.
Billy. A child on the autistic spectrum
Billy first came to Fortune Park aged four years, two months with a possible diagnosis of autism. He was a happy child, loving and affectionate with his family members and secure in their love for him. Autism affects three areas of a child's development: social interaction, social communication and imagination. It can be hard to 'get inside the head' of an autistic child and they often seem to be in their own private world, but we need to understand their world if we are to help them and their families.
Autistic children can be very different from each other, because:
* There is a spectrum of disability within the diagnosis and the basic three impairments can occur with differing degrees of severity.
* Not all of the three areas of impairment may be affected to the same degree.
* All children have their own personalities which affect how they react to their disability.
* All children have their own families and social environment which affect their development.
* Access to and quality of education can have a marked effect on behaviour.
Our first job was to see how autism had affected Billy's development. His key worker observed him during the settling-in period and discussed her observations with his mother. When he was upset she would show him a photograph of his mother and say 'mummy's gone, back soon'.
Billy would repeat, 'mummy gone, back soon', a ritual that helped him settle and reinforced the memory of her return. She also constantly repeated the routine of the day, which introduced an element of predictability to his day and helped him feel safe.
Billy quickly settled and we observed:
* He had stilted speech and had difficulty understanding all but simple language.
* He didn't understand taking turns or sharing.
* He played alone and chose the same limited range of activities.
* He became anxious and violent if his space was invaded.
* He would misunderstand what had happened in many situations; for example, he would apologise when he was the wounded party.
* He had rituals that seemed to help him feel secure, such as repeatedly lining up animals, but he didn't know how to pretend with them.
* He would become upset with changes to the routine.
* He was often in his own world and at these times he was difficult to reach.
We drew up an Individual Education Plan and worked on it with his parents.
We would praise Billy's positive behaviour immediately in simple clear language, for example by saying, 'Good sitting, Billy'. We would 'sub-title' his actions simply and clearly to help develop his language, by saying, for example, 'Billy's climbing up the steps, good climbing, Billy'.
We taught him the names of the peers and grown-ups in his group with the use of photographs and always referred to everyone by name. We warned him before changes to routine, saying, 'No singing today, Sarah's party today instead.'
His key worker developed his social skills using simple strategies. To get him to participate in a broader range of activities she warned him five minutes before the imposed change. She would accept any level of involvement in a new activity from him, explain it, praise it and offer extension sensitively -'Billy's watching Mason paint up and down, good watching, Billy. Billy's turn now?' To develop his symbolic play she would copy his play alongside him, then encourage a small change - 'Oh dear, elephant's fallen over, hurt his leg, give him a hug.' She also ran a small daily story group with a repetitive structure in which she could teach turn taking, sharing and sequencing.
She worked on this programme for the next year, extending and refining it as necessary. In addition, Billy had intensive speech and language therapy.
He left us when he was five to go to a local primary school with his speech, listening and attention skills greatly improved. He was beginning to negotiate with other children and could take turns and share well. He also chose to access all the activities in the nursery and was even starting to role-play.
OLIVER. A complex medical history
Oliver has been to hospital more times this month than most of us have been in our whole life. That's normality for him. Oliver was born with a rare syndrome that creates medical complications all the time and the doctors are unsure of what to do or what will happen next. He is four years old and has attended Fortune Park for two years, building up a range of relationships with the children and adults that have enabled him to become more confident and independent. He is popular and happy and spends much of his time with a special group of friends who value his friendship and company.
When he first arrived we relied heavily upon his mother for help in our medical dealings with him. Every one in the team needed to deal with his daily medical care in a calm and efficient way so that we could develop strategies allowing him to participate normally in the nursery day. This part of dealing with Oliver was comparatively easy, but it was much harder to know how to help him come to terms with the social and emotional implications of his condition. He needed to cope with the constant, sometimes painful and often frightening interruptions to his life at home and at nursery. He had to cope with the inevitable questions from peers about his medication and his absences and to be open to discussions about his needs. He also needed to feel that everything was worthwhile and sometimes life was just great.
Oliver's mother has formed a close relationship of mutual trust and friendship with the staff. His key workers have had to work slowly and sensitively to help him be naturally integrated into the group. Oliver has to be given medicine through a 'Mickey button' in his chest half an hour before he eats, to help him digest his food. At first he was shy about others seeing him having his medicine, but now he is happy to have it wherever he is and he likes his friends to help. Going to the toilet was also an issue for him. He wouldn't go with anyone in the toilet except his key worker and she had to stay outside the stall. Now he is just like any other child.
Oliver hates going to hospital. He is an angry and difficult patient and sometimes he takes his anger out on his mum. After all, how does a child come to terms with a parent who loves him and yet keeps taking him to this place where they hurt him? He also knows how upset his mother gets about his condition, and feels bad about that. One way to help him come to terms with all his anger and frustration is through role play. We have a 'hospital' in the nursery where all the children can play out their ideas about illness and hospitals. Here Oliver is the expert. In this creative situation, with the help of a supportive adult, he regularly plays out his experiences, takes risks and negotiates relationships in a safe way. He can reflect upon his experiences and try to make sense of them.
Answering questions and talking to children about why Oliver has to go to hospital so often and to have his medicine is a natural part of all our work with children. We all need to think carefully for words to express how we are, how we feel and who we are so others can understand how our lives are the same and how they are different. This is essential for all children but especially for all the 'Olivers' who feel so different but whose basic needs are so the same.
Ryan a child with many disabilities
Ryan came to Rosedale when he was about a year old. He had been born prematurely and had had a severe brain haemorrhage at birth. He was then oxygen-dependent for 101 days. This left him with some visual and hearing impairment. Ryan also has mild cerebral palsy and respiratory distress syndrome, which means he is prone to stop breathing if he gets a cold or flu. He finds it difficult to swallow and has a husky whisper of a voice.
He also has some emotional and social difficulties. The centre has been able to include Ryan very successfully and we are proud of the enormous progress he has made in the three years he has been here.
We value the support we have had from the speech therapists and physiotherapists, who visit two or three times each term and liaise with the key worker to produce a work programme for Ryan. We get some extra money from the local authority to give Ryan additional support. At first we focused on his behaviour, helping him get used to the centre and understand what was going on. We then focused on a programme of speech therapy and he has recently been assessed as having very good speech and language skills.
Now we are working with him on recognising and talking about his emotions and feelings.
Interestingly, his medical and physical needs are sometimes linked in ways we hadn't expected. When visual impairment was diagnosed and he started wearing glasses, his behaviour improved - all of a sudden a lot of things made more sense to him because he could see them better. When his glasses broke and his hearing deteriorated because he had a cold, we saw a deterioration in his behaviour.
His progress has also been helped by the support of his parents. They have always come to meetings and helped put together Individual Education Plans.
Recently we did a parents' survey and several commented that one of the things they liked about the centre was having children with a range of needs, because their children were learning to grow up with difference as a part of everyday life.
At the centre we work as a team on every child's needs. Everyone knows about Ryan, so the strategies we have agreed on are carried out consistently by all the staff. We think that is one of the reasons he has done so well here. We value the strong support from therapists and the partnership we have built up with his parents. But of course one of the most important factors in Ryan's success has been his own determination.
When he was born he had to struggle to survive, and he is a really determined child. We will miss him when he goes on to primary school, but we are confident that inclusion has worked for Ryan at our centre.
