Emotional Intervention in Infancy and Early Childhood (0-3) in Rehabilitation Day Care Centers A Work Model The Braman Institute for Emotional Wellbeing Early Intervention Program | Beit Issie Shapiro
3 The Braman Institute for Emotional Wellbeing Early Intervention Program | Beit Issie Shapiro Emotional Intervention in Infancy and Early Childhood (0-3) in Rehabilitation Day Care Centers A Work Model
4 Writing and professional content Shafi Mashiach, Director, Dual Diagnosis Unit Professional Director, Early Childhood Emotional Intervention Program In collaboration with the Early Intervention Emotional Therapy Staff: Orit Bichler, Anat Langbord, Anat Tzur Knowledge management, structuring and editing Dr. Benjamin Hozmi, Ms. Lital Shani and Ms. Yael Yoshei Library science Ms. Tova Eliasaf Beit Issie Shapiro's Knowledge Resource Management Editing of the Hebrew Version: Ms. Efrat Shachar Translation and Editing: Ms. Karen Gilbert Layout: Nili Goldman Production: New York New York (Israel) Ltd. © All rights reserved to Beit Issie Shapiro – Publishers Do not reproduce, copy, photograph, record, translate, store in a database, transmit or receive in any way or means electronic, optical or of any kind the material contained in this book. Commercial use of any kind in the material contained in this book is strictly prohibited without written permission from the publisher. October 2024
5 This Work Model is dedicated to Norman and Irma Braman and their daughter Debbie, from Miami, Florida. Norman, Irma and Debbie have been friends and faithful partners of Beit Issie Shapiro for over 35 years. They established the Braman Foundation, and, through its activities, they demonstrate the great importance of emotional therapy for children, adolescents and adults with disabilities, as an important factor in their development. We are grateful to the Foundation for its support in the establishment of the Institute for Emotional Wellbeing, which includes emotional therapies for infants and toddlers with disabilities, a Dual Diagnosis Unit and a center for emotional therapy for adults with disabilities, as well as research, outreach and training in the field. Michal Aharonoff Ben-Rei was a clinical psychologist who dedicated her life to helping those in need, via a number of social and community projects. Her friends and family decided to fulfill her vision to improve the emotional wellbeing of children with disabilities and their families, by the founding of the pioneering Early Childhood Emotional Therapy Center. This Guide translates this vision into a working model that documents and articulates Beit Issie Shapiro’s work in this field. With Thanks to the leading staff at the Braman Institute: Lily Levinton, former Professional VP at Beit Issie Shapiro Yitzhak Hirshberg, former Director of the Center for Emotional Therapy for Children and Families at Beit Issie Shapiro Limor Meirovitch, Director of the Center for Emotional Treatment Beit Issie Shapiro. A special thanks to Edna Karni, Director of the De Lowe Rehabilitation Day Care Center and to the daycare staff who were important partners in the development and implementation of this project. Thanks to Prof. Miri Keren, who continues to provide professional support to the project from the day it was established, with dedication and professionalism.
6 Individual therapy for the young child, and parental guidance 39 Parent groups 42 Supervision groups for health professionals and kindergarten teachers 43 Supervision for the kindergarten assistants 45 Clinical supervision for the emotional therapists 47 The end of the intervention and separation processes 48 Part C – Challenges and Dilemmas 49 Parents who have difficulty attending emotional therapy 49 Emotional work within a multi-professional team 50 Who does this information belong to? Recording and storing information 51 How do you integrate emotional language into a multi-professional team? 53 Part D - Infrastructure: Personnel and Physical Infrastructure 55 Personnel 55 Emotional therapist 55 Emotional therapy coordinator 58 Social worker at rehabilitative day care centers 59 Content Executive Summary 9 Introduction 13 The Braman Institute for Emotional Wellbeing 13 The Early Childhood Program (Michal Aharonoff Foundation) – Overview and Rationale 14 Part A – Theoretical Introduction 17 Early Intervention 17 Early Intervention for Young Children with Disabilities 18 Emotional Development among Young Children with Disabilities 19 Part B – The Model and How to Implement It 25 Absorption and acclimation to the rehabilitative day care center 26 Emotional intake meeting 27 Transdisciplinary meeting 31 Mapping of emotional needs and devising an emotional therapy program 32 Implementation of the working model for emotional intervention 35 Parent-child therapy (dyadic therapy) 36 Parental therapy 37
7 Pediatric Psychiatrist / Pediatric Neurologist / Rehabilitation Doctor 61 Physical infrastructure 62 Part E – Insights from the Formative Assessment and Quantitative Study 65 Quantitative study – parents 65 Quantitative research – kindergarten assistants 68 Formative assessment 70 Conclusion and Recommendations 72 References 75 Appendices 79
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9 Executive Summary “Early intervention” is a concept that refers to the provision of support that is adapted to the needs the preschool child, to help him advance in his first years, in all areas of development. This intervention approach emphasizes the child’s domestic and educational environments, which enable him to develop as well as possible, despite the inherent challenges with which he arrived in the world. In the case of infants and toddlers with developmental disabilities, early intervention is all the more critical. Their functioning in the various developmental areas is substantially determined by the genetic and neurological profile with which they were born, or by impairments incurred around the beginning of life (traumatic birth, premature birth, etc.) However, the young child’s environment also has a considerable impact on his development. Hence, an adapted environment that is attentive to the child’s developmental needs, combined with an early intervention approach, can significantly affect his development. In addition to adapting the environment to the child’s functioning, the role of a multidisciplinary staff is to provide emotional support to the family members. Based on this approach, the Braman Institute developed an integrative biopsychosocial intervention model for rehabilitative day care centers for children with developmental disabilities. At the center of this model is an approach that calls for early and comprehensive intervention in the young child’s life and their environment. This intervention includes an expanded component, in addition to the standard “basket” of tools that already exists at rehabilitative day care centers, and is a response to the emotional needs of the child, and his relationships with his parents and staff members. Thus, the educational, rehabilitative and emotional spheres are firmly intertwined and complement each other. The emotional support provided by the day care center is provided to the child himself, his parents and the professional staff, as they are a central part of the child’s life. This is provided in addition to educational and rehabilitative support, and helps the child to achieve optimal physical and emotional development.
10 The theoretical model underlying this approach is based on extensive literature in the fields of Attachment and Theory of Mind, which refers to the ability to attribute ideas, feelings and intentions to another person. Hence, the work of the emotional therapist, with both the families and the staff, relies on theories of mentalization and reflective functioning. We also use additional theoretical conceptualizations, which have been developed from knowledge accumulated over years of providing emotional therapy to people of all ages with disabilities. This includes knowledge regarding mental processes, such as coping with anxiety, loss-related grief, becoming a special needs parent, the impact of challenging parenting on parental relationships, and an understanding of family dynamics, including the influence of siblings. The emotional therapists employ all of this knowledge to empower the parents’ reflectivity in coming to terms with their child’s disability, and with being parents to a child with a disability. In this way, the contribution of the emotional therapists, via the interaction and exchange of information with the therapeutic team, leads to more inclusive, valuable and effective functioning of the multidisciplinary team. The first part of this Guide includes a theoretical review of the subject of early intervention in early childhood, and emotional development among young children with disabilities. It presents the key elements of the integrative approach that forms the basis of the working model in the early childhood emotional treatment program. The second part presents the model and how to implement it. It describes the different stages of implementation, starting from the transdisciplinary evaluation meeting, through mapping the emotional needs of the child and his family and formulating the treatment plan, to implementation of the model via a broad range of individual and group interventions: one-on-one therapy with the child together with parental guidance; emotional therapy for the parents; parent-child therapy (dyadic or triadic); and supervision for the staff members. The third part presents challenges and dilemmas that arise when implementing the model, and suggests ways to handle them. The fourth part sets out the personnel infrastructure required to implement the model, including specifying the various roles and professional backgrounds
11 required, and their areas of responsibility. It also sets out the physical infrastructures that facilitate the provision of optimal treatment. The fifth and final part of the Guide presents insights gained from both a formative assessment and a quantitative study that examined the model’s effectiveness. Findings indicate that the intervention contributed to increased reflective functioning among parents. The study also found that the higher the reflective functioning after the intervention, the higher the increase in proactive coping and the coping style of support and emotional ventilation. The study’s findings among kindergarten assistants show that there were no differences in the assistants’ reflective ability before and after the intervention. It may be that the assistants’ high initial level of reflective functioning explains why there was no significant change in their reflective ability following the intervention. This Guide has been produced with the aim of describing the components of the working model of emotional therapy at the rehabilitative day care center, including the methods of implementing it and the functions required to do so. The purpose of the model is also to suggest ways to implement and integrate it at all rehabilitative day care centers in the State of Israel. This model can be reproduced at any rehabilitative day care center. Given the importance of the emotional sphere, we call on the Ministry of Welfare, which is responsible for the operation of rehabilitative day care centers, to include the emotional element in the array of treatments provided to infants and toddlers.
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13 Introduction The Braman Institute for Emotional Wellbeing Beit Issie Shapiro is an organization that develops services and models for interventions for people with disabilities, for whom satisfactory support has not yet been found. The purpose of the organization is to develop evidencebased practices and to distribute them to the wider public, so as to increase the pool of people who can benefit from these developments, thereby leading to improved quality of life for this community. The Braman Institute for Emotional Wellbeing was founded at Beit Issie Shapiro in 2019 as an all-inclusive service, which brings together all the emotional intervention services that have been developed in the organization, while also working to develop new solutions and models for people with disabilities, all based on evaluation and research. The Braman Institute was established in order to gather, standardize, expand and develop the work in the field of emotional support that has been taking place at Beit Issie Shapiro for three decades, at the Emotional Therapy Center, the Dual Diagnosis Unit and the Aaron De Lowe Early Intervention Center. The Institute also aims to make an impact on policy changes in the field of disabilities, and to expand the emotional support provided to people with disabilities. The Institute works to provide solutions for people with all kinds of developmental disabilities, of all ages, from infancy to adulthood.
14 The Braman Institute working model consists of six key components, as shown in Figure 1: Figure 1: Braman Institute Operating Model The Early Childhood Program (Michal Aharonoff Foundation) - Overview and Rationale In 1983, Beit Issie Shapiro founded the De Lowe Center, a pioneering rehabilitative day care center, as a comprehensive framework for early intervention for infants and toddlers with disabilities. Since the first rehabilitative day care center in Israel was established at Beit Issie Shapiro, dozens of similar centers have opened up across the country, providing young children with an educational framework that includes a broad range of services in the healthcare field. Oftentimes, whether at rehabilitative day care centers or in other frameworks, mental health among young children with physical disabilities is considered a
15 low priority issue. This is due to the heavy workload, and the time and resources spent providing other important developmental-rehabilitative solutions. However, a young child’s emotional development has implications for his self-perception in adulthood, and for his relationship with his environment. Hence, the organization’s management identified a serious need to include emotional interventions in the selection of support services provided to infants and toddlers with disabilities and their families. After 25 years of early intervention in the lives of infants, toddlers, children and adults with disabilities at Beit Issie Shapiro, when the Braman Institute was established in 2018, it was decided to focus the Institute’s activities on the field of early intervention in infancy and early childhood (0-3) for children with disabilities. The decision to focus on this age group was based on Beit Issie Shapiro’s decades of experience of early intervention in early childhood, and on studies that show that emotional investment at these ages is the most significant and has long-term effects. This is true for young children both with and without disabilities. The development of the Early Childhood Program at the Braman Institute was intended to structure and deepen the extensive knowledge and experience accumulated at Beit Issie Shapiro in the field of mental health in early childhood. As part of the program, an emotional therapist was added to the day care staff of each kindergarten class. Her role was to support the children and their families and to give them tailored emotional therapy as part of the services in the program. In addition, the emotional therapist supports the day care staff with respect to issues relating to the emotional aspects of the children’s lives, and provides emotional therapy as an integral part of the rehabilitative day care center’s biopsychosocial approach. The emotional therapist’s role is described in detail later on. The Early Childhood Program was implemented at Beit Issie Shapiro’s De Lowe Early Intervention Center, and was accompanied by evaluation, information gathering and research. The research study examined the reflective ability of the staff and the families of the children at the day care center, and the extent to which this changed, by measuring “before” and “after” the emotional intervention. The De Lowe Center has four kindergarten classes, with a total of 44 children. Of these, approximately half move on to new settings each year and new children join.
16 The early childhood emotional intervention model was developed and established on the basis of our work at the Center. After the early childhood program had been running for four years, a systematic working model for emotional intervention in early childhood was formulated, featuring three groups: the child, the family and the staff. The components of the model will be set out in the coming chapters. This Guide will describe the components and features of the working model, the methods that may be used to implement it and the functions required for it to work. Following this, the findings from the evaluation and research program that accompanied the program will be set out, as they relate to the model’s components, and the key insights from the study will be presented. These data are a part of the comprehensive research that accompanied the early childhood program. Finally, we will suggest ways to implement and assimilate the model within frameworks for young children with disabilities, and we will present recommendations going forward.
17 Part A - Theoretical Introduction Early Intervention Comprehensive responsiveness to the needs of toddlers in early childhood has significant value and long-term impact on their entire life course. Early intervention during a period of development and growth is more effective than intervention at later life stages. This investment affects coping ability, social competence, and even his integration in society later in life (Guralnick, 2011). “Early intervention” is a concept that refers to the provision of support that is adapted to the needs the preschool child, to help him advance in his first years, in all areas of development. This intervention approach emphasizes the child’s domestic and educational environments, which enable him to develop as well as possible, despite the objective difficulties with which he arrived in the world. Based on this approach, the Braman Institute developed an integrative biopsychosocial intervention model for rehabilitative day care centers for children with developmental disabilities. At the center of this model is an approach that calls for early and comprehensive intervention in the young child’s life and their environment. This intervention includes an expanded component, in addition to the standard “basket” of tools that already exists at rehabilitative day care centers, and is a response to the emotional needs of the child, and his relationships with his parents and care team.
18 Early Intervention for Young Children with Disabilities In the case of young children with developmental disabilities, early intervention is all the more critical. Their functioning in the various developmental areas is substantially determined by their genetic and neurological profile with which they were born, or by impairments incurred around the beginning of life (traumatic birth, premature birth, etc.). However, the child’s environment also has a considerable impact on his development. Hence, an adapted environment that is attentive to the child’s developmental needs, combined with an early intervention approach, can significantly affect his development. One of the central goals of early intervention is to increase awareness among the parents and significant caregivers (such as educational and therapeutic staff) of the challenges involved in early intervention and of its positive effects. Guralnick and Bruder (2019) believe that one of the main goals of early intervention is to teach the child’s parents and caregivers the positive impact of contingent and appropriate interactions, and to provide them with tools to create such interactions. The tools required for these interactions include knowledge of early childhood developmental stages and of various developmental difficulties, and, most importantly, the caregivers’ knowledge of the functioning components of each child under their care. This knowledge enables the caregivers to find ways to adapt the environment for the child’s optimal development. It will help the child’s close environment create contingent and appropriate interactions with him that will support his development. According to this approach, the role of the multi-disciplinary staff, in addition to adapting the environment to the child’s various functioning components, is to provide emotional support to the family members. This support should give the family a sense of confidence and competence to cope with the child’s special needs in the domestic environment (Guralnick & Bruder, 2019).
19 Emotional Development among Young Children with Disabilities In 2021, Dr. Tali Hindi conducted a comprehensive review, which was published in her article (in Hebrew) “Mental Wellbeing of People with Disabilities – a Review of Research, Therapeutic Solutions and Policies in Israel and Around the World” (Hindi, 2022). This review sought out studies that examined emotional aspects of young children in infancy and early childhood. The search included studies conducted in the preceding five years that looked at infants and toddlers with normal development, and those with disabilities. There are a few key insights that can be gleaned from these studies: • There are four main approaches on which early childhood interventions are based: relationship-based interventions, community-based interventions, family-based interventions and culture-based interventions. • The majority of interventions in the emotional arena are based on the relationship approach, and focus on the parent-child interaction, which is in contrast with more traditional approaches that treat the behavior of the child and the parent separately. • Assessment of parent-child relationships is a relatively young field of research, but there is evidence that this approach is promising. • There are very few studies that examine the field of interventions for the caregiver (professional staff). • The majority of studies are not focused on children with disabilities and their families, but on the general population (Hindi, 2022). Schore (2001) proposed a multi-disciplinary approach that is focused on attachment patterns and their impact on various structures and regulatory functions as an explanation for normal development. He cites parts of Attachment Theory (Bowlby, 1969), which claims that the developmental process can be optimally understood as a product of the interaction between the unique genetic endowment that the child has received and the unique environment in which the child lives. It can be assumed that a child born with a neurodevelopmental delay may have poor interactive abilities due to his disability (sensory, motor,
20 communication impairments, etc.). In addition, sometimes the parent also has difficulty adjusting the skills required on his part in the face of these developmental challenges. Hence, the child may be more likely to develop vulnerability from relational trauma, compared to a child without developmental delay. The literature supports this hypothesis. In studies conducted in the United States and the Netherlands, it was found that among children with disabilities less than 50% developed a secure attachment pattern, compared with 65% among children without disabilities (Alexander et al., 2018). This finding has a variety of explanations: One view brings findings that show that parents of children with disabilities describe themselves as being under stress, and report tensions in their relationships with their partners. Furthermore, these are often populations that are suffering from poverty. The studies that talk about the parents’ emotional state show that parents who have come to terms with their child’s diagnosis manage to develop a secure attachment pattern with the child (Koren-Karie et al., 2002; Oppenheim et al., 2012). Another explanation is based on the hypothesis that children with disabilities may have fewer possibilities for emotional expression and responsivity, and this affects the attachment process (John et al., 2012; Gul et al., 2016). Other studies show that children with disabilities have poorer communication abilities and have difficulty expressing their needs, and hence the great challenge for the parents is to be attentive to their needs (Howe, 2006; van IJzendoorn et al., 2007). Another study shows that 35% of the fourth attachment group (Group D, insecure or disorganized attachment) were children with disabilities. This attachment pattern is often related to conditions of parental neglect. The researchers claim that these findings cannot be explained solely by parental neglect, even if this attachment pattern is found at a higher rate among children with disabilities. They say that it is also due to a parent’s unresolved trauma and loss, or a result of the child’s prolonged or multiple separations from his parents (Granqvist et al., 2017). Many experts, including national authorities such as the Australian Children’s Education and Care Quality Authority, recommend focusing on early childhood interventions (ECI), which promote and strengthen the parents’ reflective functioning, as well as promoting and strengthening the parent-child bond.
21 The following is a review of five studies in the field of mental health that focus on parents of children with disabilities, and were conducted in the years 20162021 (Hindi, 2022): a. A study conducted by Sealy and Glovinsky (2016), among parents of children with neurodevelopmental disabilities, aged two to six years, examined the effect of dyadic parent-child intervention on the parent’s reflective functioning. The intervention included parent-child play followed by a conversation with the parents about their feelings and the child’s motivations (mentalization). The study’s findings showed that the group of parents that underwent the dyadic intervention received a higher score in reflective functioning relative to the control group. The study also found that treatment in a short timeframe was more effective in improving the parent’s reflective functioning. b. An evaluation study conducted by Burton et al. (2018) of the “Nurturing Program,” examined the effectiveness of the intervention program for parents of children with special needs and health challenges (CSNHC). The families in the treatment group received twelve sessions of specialized content and were assigned a case manager. The families completed a questionnaire about their attitudes towards child rearing and family empowerment before and after the intervention. It was found that empathy towards their children increased among families who participated in the program. The study showed that the two types of intervention (case manager and the general intervention) provide the parents with coping tools and empower them. c. The third study is a randomized controlled trial of early intervention for toddlers at high risk for CP. The intervention had two components: a personal physiotherapy coach for the family, and a neurodevelopmental component with a hands-off approach, which challenges the child to find his or her own adaptive motor strategy. The study examined the changes in family functioning and the child’s level of participation and activity. The intervention lasted one year, during which one group received the intervention and a second group of children received ordinary physiotherapy. On the family empowerment scale (FES) and the children’s functioning measures there were no differences between families that received the intervention and those that only received physiotherapy. However, the family quality of life significantly improved among those that received the intervention versus
22 the control group, mainly in measures of perception of the child’s general health and the parents’ emotional wellbeing (Hielkema et al., 2019). d. An evaluation study (Kasparian et al., 2019) of emotional interventions aimed at treating parents of infants aged 0-12 months who suffer from congenital heart disease (CHD), and who needed surgery and hospitalization in intensive care units, conducted a comparison of different interventions, and found that all were carried out in person (as opposed to online therapy, for example), but each one used a different therapeutic approach (parent-child interaction, early pediatric palliative care, a psycho-educational approach, parenting skills training, and family-centered nursing). Four out of the five interventions succeeded in reducing anxiety, although the quality of data that was collected was low. In addition, positive results were also found for maternal coping, mother-infant attachment, parenting confidence and satisfaction with clinical care. There were no findings of improvement of quality of life for the parent or family. In conclusion: It is striking that research on issues related to the emotional development of young children with disabilities is scarce. The studies that focused on the interaction between parents and children with disabilities showed that less secure attachment processes are observed among this population than among young children with normal development. Also, it seems that early intervention of various kinds improve the quality of life of families of toddlers with disabilities. The concept that took shape at the day care center is an integrative approach, which seeks to address all the needs of the child and his family. According to this concept, the educational, rehabilitation and emotional fields are intertwined and complement each other. Hence, the emotional support at the day care center includes working with the child himself, his parents and the care team, as they play a central role in the child’s overall care. The emotional therapy comes in addition to the educational and rehabilitation services. In this way, more comprehensive and complete care is provided that will promote the young child’s physical and mental development. The theoretical model of emotional intervention at the day care center is based on extensive literature in the field of Attachment and Theory of Mind, which
23 refers to the ability to attribute ideas, feelings and intentions to another person (Premack & Woodruff, 1978; Baron-Cohen et al., 1985). Hence, the work of the emotional therapist, whether with the families or with the care team, relies on theories that relate to mentalization and reflective functioning. Developing the reflective functioning skills of parents of young children is especially significant, as children at this age begin to demonstrate an understanding of other people’s emotional states (Sealy & Glovinsky, 2016). Theoretical models have assumed that these abilities develop when the child acquires language, and they derive from inborn mechanisms. However, researchers Target and Fonagy (2002) claim that this approach does not reflect the bi-directional connection that derives from the attachment relationship between the parent and the child, and that this lays the foundations of the child’s future abilities to understand the emotional states of others, as an adult. Fonagy, et al. (1991) claim that reflective functioning demonstrates the extent to which a parent can ascribe meaning to his own internal experience and to that of his child. It is also claimed that a parent with reasonably good reflective abilities can hold his child’s thoughts, feelings, beliefs and intentions in his mind, and wonder about how these emotional states affect the child’s behavior. At the same time, a parent with good reflective abilities is able to recognize and examine his own emotional state, and to understand the impact that it has on his relationship with his child. Later in their article, Target and Fonagy (2002) claim that the mentalization process enables a person to interpret the reasons for his own behavior or that of others, by examining and analyzing emotions, beliefs, intentions and desires, whether conscious or unconscious, and to act accordingly. The “mentalization process” concept comes from the theory of mind, which refers to the ability to ascribe ideas, emotions and intentions to another person (Premack & Woodruff, 1978; Baron-Cohen et al., 1985). The mentalization process also includes understanding the impacts of this process on the other person’s behavior, and on his ability to regulate his emotions and behavior. It is important to state that the theoretical model of emotional intervention at a day care center is based on additional theoretical conceptualizations, and has emerged from the knowledge and understanding that have accumulated over years of providing emotional therapy to people of all ages with disabilities.
24 This knowledge relates to emotional processes that include coping with anxiety, loss-related grief, becoming a special needs parent, the connection between challenging parenting and parental relationships, and an understanding of family dynamics, including the influence of siblings. The emotional therapists employ all of this knowledge to empower the parents’ reflectivity while coming to terms with their child’s disability, and being parents to a child with a disability. In this way, the contribution of the emotional therapists, via the interaction and exchange of information with the care team, helps the multidisciplinary team to provide emotional support that is more containing, beneficial and effective.
25 Part B - The Model and How to Implement It The systematic working model formulated in the Beit Issie Shapiro Early Childhood Program includes the young child, his parents, the day care center staff, and the support provided by the emotional therapists. Figure 2: Systematic working model for early emotional intervention in early childhood The emotional intervention process at the day care center is spread out over a school year, and includes the process of acclimation to the day care center, identifying needs, and execution of the emotional intervention.
26 The following flow chart describes the different stages of the process: Absorption and acclimation to the rehabilitative day care center Attending an early intervention day care center for the first time is a complex and meaningful experience for the young child and for his family. The acclimation process also has emotional dimensions that significantly affect the child’s adjustment to his new educational framework, and usually this is his first ever experience in an educational institution. In the first few weeks of acclimation, the emotional therapist’s perspective can shed extra light on a number of factors, including the child’s inner world, his level of communication, and his ability to separate from his parents. At this stage the emotional therapist joins the daycare team and begins to meet with the parents in the intake sessions described in the next episode.
27 Emotional intake meeting In the first few weeks of the year, an extensive emotional intake meeting takes place, which includes an in-depth interview with the parents, in which they provide details about their child. This meeting is conducted with the emotional therapist of the day care center class. The purpose of the intake meeting is to obtain information about the child, as well as to form an overall impression of the family. This meeting also enables the parents to get to know the emotional therapist as someone who provides individual and broad support throughout the year. In the past, prior to the introduction of emotional therapists at the day care center, the center’s social worker would conduct the intake meeting for each child. Since the start of the program and the emotional therapist joining the center, she has been a part of the kindergarten staff and responsible for conducting this meeting. This new arrangement enables us to convey to the parents and staff that the emotional dimensions of both the child and his parents need to be considered. The clear message is that we ascribe importance not only to the young child’s motor and communication development, but also to the emotional sphere. In order to improve our understanding of the emotional elements, a special “intake form” was produced that focuses more on the following dimensions [Appendix 1 – Intake Form]: • The experience of starting to attend and acclimate to the day care center – The initial period at the early intervention day care center is usually a meaningful and dramatic period for the child and his parents. The therapist meets the parents for the intake meeting in the first few weeks after he has joined the kindergarten, and we have found that it is generally appropriate to start the intake meeting with a question about the child’s experience starting at the kindergarten, and how he is acclimating. Sometimes, separation and acclimation are key issues in the child’s life at this age. Often, starting to attend the day care reflects, increases and exacerbates the issue of separation in the child’s life. For most children, starting at the day care center is their first time separating from their parents since birth. For children with disabilities and their parents, this experience is extremely significant, and can present the parents
28 with dilemmas about issues such as their ability to trust others to care for their child, and their ability to trust their child to manage without them. • Birth, beginning of life and receiving the diagnosis – This is a key part of the family dialogue and a central subject in individual and group therapies. Some parents describe the beginning of their child’s life in terms of trauma. Oftentimes, the beginning of life for these children is dramatic and unusual (e.g., early birth, prematurity, traumatic birth, neonatal intensive care unit (NICU)). In some cases, the parents are informed close to the birth that their child has a congenital syndrome or disease, while in other cases the disability becomes apparent in the first few months of life. In most cases, these events take place in the first few months of the child’s life, and are a traumatic experience that has barely been processed by the time the child starts attending the center. It therefore comes up at the intake meeting as primary and highly complex “raw material.” The parents’ description of their experience of discovering or receiving the diagnosis opens a window to what they have gone through, and are still going through, and will continue to resonate in all the therapeutic processes that they will undergo at the day care center. • Developmental lines – The assumption is that the parents have provided the child’s developmental history to the day care staff. This information is included on the intake form so as to provide a complete picture and make it clear that this topic may come up as part of the therapeutic discussion. The emotional therapist will decide during the meeting if, and to what extent, it is necessary to delve into the details. • The child’s name and how it was chosen – The child’s name and how the parents chose it are additional pieces of the puzzle, and they help us to build an emotional picture of the family. Sometimes, this subject is emotionally charged, and discussing it helps form a deeper understanding of various topics, such as the bonding processes with the child, the parents’ fantasies during the pregnancy, their thoughts ahead of the birth and the parents’ perceptions of their child. • Parental history – The intake meeting addresses the parents’ history. Part of this history includes significant life events, traumas, losses and crises
29 throughout their lives. The message that we want to convey is that the parents’ backgrounds and the resources with which they have come to special parenthood constitute an important part of the therapeutic work at the day care center. It is also important to obtain information about the various support networks available to the parents – extended family, friends, community, etc. It is crucial to understand the family structure, which is an additional component in the parents’ ability to cope with the task of raising their child. • The parents’ relationship – The form includes reference to the issue of the parents’ relationship and parental partnership. This information will contribute to a deeper understanding of the parents’ resilience and weaknesses.] Siblings – It is important to consider the siblings of children with disabilities. One should understand, via the parents, the experience of the siblings and the questions that occupy the parents with respect to them. For example: Should we tell the older sibling about his brother’s diagnosis? How can we give all family members the attention that they need? How should the family reorganize itself after receiving the news? The intake meeting is a therapeutic act in itself and not simply an informationgathering session. It enables the emotional therapist to form more of an impression from non-verbal and non-content bearing information, such as body language, speech tone and behavior in the meeting. The emotional therapist also listens to the topics that the parents choose to focus on. She observes what happens in the room when one of the parents is agitated or annoyed. She sees how the parents look at each other during the meeting, if there is a good atmosphere and whether the emotions that come up are appropriate for the content that the parents bring up. She is also attentive to matters that are not discussed in this meeting. There are parents who have difficulty and even refuse to answer certain questions. In such cases, the emotional therapist will respect the request, but will infer from this that perhaps this is a sensitive issue, and it would be worthwhile going back and examining it later in the therapeutic process. It is important to remember that during the meeting there are “countertransference” processes taking place, in which the therapist is attentive to the feelings and emotions that come up for herself throughout the meeting. In the supervision processes that take place on an ongoing basis,
30 the therapist will try to track the unconscious reactions that arise for her from matters that come up in the meeting. This information contributes to a better understanding of the emotional world of the parents and their child. The intake meeting lasts approximately one and a half hours, and includes an in-depth interview with the parents, using the outline on the intake form that was developed as part of the program, which gives a clear structure and an orderly framework. There is also room for discussion of substantial topics that may have clinical significance from a therapeutic perspective. The emotional therapist allows the parents to tell the story of the family and the child freely, as far as possible. Experience shows that adhering strictly to the intake form is difficult when conducting intake meetings, because of the desire to create an informal connection with the parents and to have a free-flowing conversation. Each therapist is very familiar with the intake form and chooses when and how to get to each section, so as not to spoil the flow of the conversation with the parents. For some parents, the intake meeting is a meaningful event, as the emotional therapist is the first member of the professional staff with whom they are sharing deep emotional concerns. At the end of the intake meeting, it is important to discuss with the parents the format of emotional support provision at the day care center, and to explain to them how the process will continue. It is essential that the parents know that broad support is being offered to them, and that the kindergarten teacher and the emotional therapist are the people that they should turn to regarding emotional issues or crises, via one-on-one conversations, participation in parent groups or informal meetings at the day care center. As part of the process of getting to know the child, other actions can be taken to help complete the emotional puzzle: • Observation of the child in the day care center classroom. • Joint viewing by the emotional therapist and the parents of videos of each parent playing with the child. At the end of the process of getting to know the child and his family, the emotional therapist will note down the main themes and insights that arose during the emotional intake process.
31 Transdisciplinary meeting During the acclimation process at the rehabilitative day care center, a meeting will take place that will include the child and his parents, and the entire staff of the kindergarten (kindergarten teacher, kindergarten assistants, allied health professionals, the center’s social worker and the emotional therapist). This meeting is intended to help the staff get to know the child and his parents and to form an impression of the child’s functioning and his relationship with his parents, as well as to formulate therapeutic goals for the coming year. The therapeutic goals are determined by the multidisciplinary staff at the center, together with the parents. The Transdisciplinary Assessment Form is used in this meeting [Appendix 2 – Transdisciplinary Assessment Form]. While for some families this meeting is perceived as a threatening or overwhelming situation, in most cases the transdisciplinary assessment meeting is a meaningful experience for the child’s parents. The parents experience multidisciplinary cooperation and a spotlight on their child and his developmental needs. In addition, this is the first time that the parents meet the entire staff in one place, and it is an opportunity for them to hear each staff member’s professional perspective. Furthermore, this is a chance for parents, as important and active partners in the discussion, to express their expectations from the rehabilitative day care center and from the members of staff. The important message that is conveyed in the meeting is that it is the joint mission of the staff and the parents to provide the child with the best possible support for his developmental needs. As part of the assessment process, the emotional therapist observes the interaction of the child with his parents, as well as that between the child and staff members. The parents are also asked to bring video footage of interactions between them and their child in his home environment. The role of the emotional therapist is to look at the relationship patterns of the parent-parent-child triad and try to understand the emotional dimensions of the child’s world and that of his parents. By this stage, many of the parents have already met the emotional therapist for the intake meeting, and therefore her presence as a familiar face can help the parents feel more confident at this special meeting. Sometimes, complex matters come up at these meetings that bring up intense emotions for both the parents and the staff. The emotional therapist can help to process these complex meetings.
32 Mapping of emotional needs and devising an emotional therapy program In October every year, a summary is written for the Ministry of Welfare by the day care center’s social worker, allied health professionals and emotional therapist. Following this, the kindergarten teacher and staff produce a Personal Rehabilitation Plan (PRP). The PRP is intended to promote each child’s unique goals and objectives in the emotional arena. The goals will be formulated by the emotional therapist together with the child’s parents and the professional staff. The formulation of goals will enable focused work and help mobilize the staff and parents to achieve the goals. When working in a multi-professional team with a transdisciplinary approach, it is important that each team member has all the goals set for the child in the PRP laid out before him. It is advisable to focus on measurable goals that can be added to the PRP if necessary: 1. Working with the parents on accepting their child's diagnosis. 2. Assistance with acclimation, e.g. anxiety, difficulty with transitions and changes. 3. Processing the child’s disability. However, there are situations in which we fail to identify a specific emotional goal when preparing the PRP. Our experience shows that the emotional therapist’s perspective is often required to achieve the therapeutic goals set out in the PRP. The emotional therapist provides added value by looking at the child’s emotional processes and inner world as they relate to the implementation of the PRP, and the achievement of the rehabilitation goals. Take, for example, a rehabilitation requirement that is consistent with the child’s abilities but is met with refusal and resistance. Sometimes the emotional therapist will raise awareness of the emotional cost of one therapeutic goal or another. As part of this process, there are several parallel thinking spaces. The guiding principle is to open up several thinking spaces that take into account the perspectives of the child and his family, as well as the perspective of the system. Sometimes, dilemmas arise due to the gap between the need identified by the emotional therapist, and the family’s ability to comply with the treatment; or
33 an attempt is made to strike a balance between the need for treatment and the lack of resources, or inability to fulfill all of the needs. Taking all of these perspectives into account leads to the most accurate mapping of needs. The first thinking space entails a meeting between the emotional therapist and the kindergarten staff, in which the emotional therapist describes the insights that arose from the emotional intake meeting, and her initial thoughts about the emotional needs of the child and his family. The second space is a meeting of the emotional therapy team in which stories of the child and his family are brought up for discussion, consideration and consultation. The third space involves meetings with the day care center director, the center’s social worker, the emotional therapist coordinator and each emotional therapist individually. The purpose of the meetings is to make system-wide decisions regarding the mapping of the needs of all the children in the day care center. Sometimes, we will identify a family that requires intervention but has difficulty accepting an invitation to therapy for various reasons. In other cases, parents report or feel that therapy could be more of a burden than a help. There are parents who are anxious, under stress or even traumatized, and have difficulty acknowledging the need for therapy, because their mentalization abilities have been affected. In these cases, the job of the therapist will be to help the parents understand the necessity of therapeutic intervention. The emotional therapist will continue to be in contact with parents who are not open to therapy, and will suggest that they come to therapy at a later date. In the process of identifying needs, defining the urgency of therapy and determining the appropriate setting, we will take the following criteria into account: Parent-related criteria 1. Intensity of the emotional distress. 2. Signs of stress such as low mood, lack of functioning, inability to care for the child. 3. Low mentalization abilities of the parents. 4. Parents’ difficulty seeing the child’s needs. 5. Families without familial, social or community support.
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