Positive environments for early child and family support. Part 4: A personal perspective on collaboration between health and education workers


In this serialised essay I want to explore positive and favourable environments for providing early child and family support when babies and young children have conditions that potentially reduce their capacity for development and learning.

In the first parts I will contrast the busy and often neurotic atmosphere of the hospital with the quiet and calm space that we generally assume is required for learning in babies and young children. I will then explore the implications for early child and family support much of which is traditionally hospital-based. I will then argue that society’s mind-set and approach to these children and their families should be less medical and more educational.


Positive environments for early child and family support. Part 4: A personal perspective on collaboration between health and education workers


In the first part of this serialised essay I suggested hospitals and clinics are not favourable environments to promote education/learning. In the second part I set them in contrast to places where babies and children can be relaxed, inquisitive, respected, secure and ready for learning. In the third part I suggested some moves from the health mind-set towards the education mind-set. In this fourth part I am offering some personal biography to show how my ideas began to develop. I hope it is not self-indulgent.

I would not be writing this essay if I did not have strong views on these issues so perhaps it is appropriate now to show how these views began to develop in my working life. For this I need to go back to the early 1980s in a special school in the UK’s West Midlands. I had recently moved from a London-based campaign to get people out of institutions and had a space to fill while deciding on a career direction. When I applied to the local education department for a temporary teaching post they sent me to a special school for children with health conditions and physical disabilities on the basis that I had a qualification in special education. The job was for a second teacher in the nursery.

Some history of education in England will help. Prior to 1970 children with significant  intellectual difficulties were labelled ‘mentally handicapped’ or something worse and deemed ineducable. Instead of going to school, they were ‘trained’ in training centres run by local health services. This harsh attitude gradually changed and government legislation afforded them the right to go to school where they would be taught by qualified teachers. Following this, the recommendations of the important Warnock Report (1976) were enshrined in law in 1981 saying that children with special education needs should, whenever possible, be included in mainstream schools. Different sorts of special schools would cater for children with long-term complex and multiple disabilities. Included in these were special schools for children with ‘moderate’, ‘severe’ or ‘profound’ learning disabilities (crude labels I have never come to terms with). 

This PH (physical handicap) school to which I was directed catered for children up to school-leaving age whose intelligence was ‘in the normal range’. The population of children included those with heart conditions, respiratory problems, muscular dystrophy, metabolic disorders, birth defects caused by thalidomide, etc. They were a mixed bunch in a very happy and settled school with teachers who, as far as I could see, did not impose ceilings on any child’s progress.

The school belonged to the local education authority and was a relatively new building with plenty of light and space. Class sizes were limited to 12 – 15 children with one teacher per class. There was a nursing team and a therapy team but no psychologist, social worker or home-liaison worker. Children were removed from their classroom for therapy and medical attention in another part of the school.

The situation I found in the nursery was of two groups of young children. The larger and well-established group were typical of the rest of the school population. A smaller group, entering the school quite recently in post-Warnock conditions, might otherwise have been admitted into schools for children with learning disabilities. Perhaps someone had raised questions about the intellectual capacity of these children and so they had been given the benefit of the doubt and sent to this PH school. They certainly had physical conditions including cerebral palsy, known genetic syndromes and other conditions with no label. I am sure these children, because of their levels of general functioning, would have been deemed ineducable in the recent past. Each of these children had what I now term a multifaceted condition. I learned in time that none of these children had been offered any effective early child and family support.

Nursery staffing comprised a teacher (two after I arrived), two NNEB (National Nursery Examination Board) nursery nurses and two bathroom assistants.  It was a remarkably harmonious team under the inspired leadership of the first teacher. One nursery nurse felt that the new children were not appropriate admissions while the other was warm and accepting.

There was no established curriculum for this new intake and teacher and nursery nurses by their own admission were out of their depth. These children arrived by taxi or school bus, were carried in by their escort and laid on bean bags because there was no nursery equipment for them.  They were much more ‘patients’ than pupils. They soon came under my wing as the new teacher with valid experience. This temporary post stretched into months and then years and I was able to achieve the following (briefly explained) by working collaboratively with the other nursery staff, nurses, therapists and parents:

  • The children stopped being ‘patients’. They were increasingly involved in games, social activity and learning, their personalities were recognised, hidden potentials came to light.
  • Each child was equipped, when ready, with a tailor-made nursery chair so they could sit to a table. (With the voluntary input of an unemployed carpenter.) Once a child was promoted from bean bag to chair and table they were seen in a new light. Now they could be with the other children for snacks, mealtimes and going-home songs.
  • The main body of children had a morning story-time as a group. The new group had so far stayed on their bean bags for this on the periphery. With help I made a group of these new children in a corner of the nursery with each in some sort of propped sitting position from which, if they raised their heads, they could see me and the others in the small group. It usually took about 40 – 50 minutes to get this group assembled in comfortable postures after drink and bathroom attention. The activities included responding to their name, smiling, looking at me, looking at another named child, moving hands, handling a teddy or toy, listening for their name in a song, expressing some sort of ‘yes’ and ‘no’, making simple choices and so on.
  • I worked/played with each child individually or in pairs at other times of the day. I spent a lot of time on the floor with the children to the surprise of other staff members.
  • As each child showed new understanding and skills, their parents were invited in so they could see what their child was doing and for an exchange of observations and information – the start of a home-school relationship.
  • In most cases this opened the way for me to visit the child at home. This was always a rich and rewarding experience.

The main point in all of this is that as a teacher I could not on my own create good positions for drinking, eating, listening, use of hands and for hand-eye coordination. Also, I could not create activities to promote head control (prone or sitting), moving on the floor (rolling, creeping), alternative communication including a form of ‘yes’ and ‘no’, making choices, etc.  All of this required collaboration with therapists and, when necessary, nurses  ̶  as did the design of chairs and other ‘home-made’ postural aids. An early part of my work was to build trusting relationships with these colleagues and to bring them into nursery activity instead of them seeing children in their clinical rooms. It is fair to say that these new children were largely an unknown quantity to the nurses and therapists so we were all learning together, with me supplying the education impetus to lift the children out of ‘patient’ mode.

Readers who know my work will see that the Team Around the Child approach was evolving here as was my deep respect for health professionals and the need for respectful collaboration in horizontal teamwork. I also learned good lessons here about the value of home visits and the need to respect parents and keep them fully informed and involved.

The principles I established for myself then and which have informed my later work include:

  • Seeing a child as a patient at home or in school and treating them as such is not conducive to development and learning.
  • No single person is competent to offer a whole approach to a child who has a multifaceted condition.
  • Collaboration is essential between educators, health workers, parents and others as necessary.
  • Each person’s skills are to be respected. Collective competence is created when they are all joined together around each individual child.
  • Teachers cannot function with these children without this teamwork. Collective competence must address play, learning, posture, communication, cognition, dexterity, eating, drinking, sleep, nutrition, oral hygiene, constipation....
  • When, using collective competence, a child is being encouraged, for example, to move on the floor to reach a toy, it is impossible to say what part of the activity is play, what part is therapy and what part is education. The activity transcends these labels.
  • With these children, all firm boundaries are dissolved between education and health, between teachers and health workers.

In conclusion

As I have said, in England children with intellectual difficulties were not offered education before 1970 and were catered for by health workers. Even in a school setting I had to strive to get staff to stop seeing some children as ‘patients’. The theme of this serialised essay is that we should also elevate babies and preschool children out of ‘patient’ mode, changing our mind-sets so we see them as leaning children and ourselves as educators. A major part of this is to avoid offering early child and family support in hospitals and clinics.

In the fifth part of this serialised essay I will explore the words ‘development’ and ‘learning’ to see if they mean the same thing. I will also suggest why we mistakenly use a medical approach to these children rather than an educational approach and why the word ‘therapy’ is part of our wrong thinking.

Peter Limbrick

September 2020

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