What a cutie," Zehava Kroani, an educational assistant, says to a girl who has arrived early at the kindergarten. The child stares at her with quiet eyes that thirst for attention. After a moment she says, "I am not a cutie."
"Why do you say that?" Kroani asks.
"I am not a cutie," the girl insists.
"Who told you that you aren't a cutie?" Kroani asks her, patting her on the head. After a long silence the girl replies, "Mommy."
It's clear that the little girl feels protected in Kroani's presence. She makes eye contact with her and her jumbled words tumble out. Kroani manages to extract meaning and asks, "Do you have bad dreams?" The girl nods and continues to relate from within her apparent inner chaos that she is afraid to go to sleep at night and that her mother refuses to leave her bedroom door open.
"Tell Mommy not to close the door at night," Kroani says and adds, trying to build up her confidence, "and tell yourself all the time: 'I am a sweet girl, I am a pretty girl.'" She picks her up; the girl smiles and continues mumbling to herself.
Meanwhile, more children arrive and enter from the back gate, which is slightly hidden, of Geha Mental Health Center in Petah Tikva. Some have been collected by bus from locales in the center of the country; others are accompanied by a parent.
Welcome to Flower Kindergarten, for children aged three to six. This is in effect part of an outpatient unit that operates in the hospital from 8 A.M. until 3:30 P.M. It's the only kindergarten in the country for children who have been diagnosed with serious pathologies, developmental disorders and adjustment difficulties stemming from an organic or emotional problem - or a combination of the two.
Staff at the unit, which operates in partnership with the Clalit Health Maintenance Organization and the Ministry of Education, follow a regular, daily kindergarten curriculum with an emphasis on social skills. In addition, there are therapeutic activities geared to each child, which include psychological treatment and paramedical care. The activities offered are animal-assisted, art, speech and movement therapy; there is also what is called a relaxation room. The 26 children in the kindergarten are divided into two classes; five of the youngsters, whose condition allows them to attend regular kindergartens as well, come three days a week.
"Hey, do you see these great-looking kids in my unit?" asks Prof. Sarah Spitzer, a psychiatrist, who, along with Mirit Sharir, a movement therapist, founded the program in 1986. It actually began at Beilinson Hospital in Petah Tikva, where Spitzer was then working, and moved to the present location in 1997. She draws my attention to four- and five-year-olds, who are waiting in line with their parents for an evaluation. The children blush and smile with curiosity.
"And this gorgeous kid - when did you last see a kid as gorgeous as this?" Spitzer says, bending down over a little boy with a pronounced limp. She engages him in a lively conversation, laughing with evident enjoyment. Though she has been running the unit for 24 years, every toddler Spitzer encounters still brings out the child in her.
The unit treats about 110 children a year: In addition to the 26, there are 80 other kindergarteners and first-graders who are ambulatory patients in its clinic. The staff includes two additional psychiatrists, each of whom is in charge of a class: Dr. Miriam Peskin, Spitzer's deputy, who specializes in psychiatric care of the family and of young children; and Dr. Ruth Baruch-Movshovitz, a specialist in child, adolescent and adult psychiatry, who heads the kindergarten staff.
"The children come from all social strata," Spitzer says. "They might be the children of career-oriented couples from affluent homes, who have developmental and emotional problems and whose parents lacked the knowledge or the emotional and physical capability of responding to their needs. Or they might be second- or third-generation children of poverty and violence - children whose parents are rehabilitated drug addicts or are engaged in harsh divorce proceedings and are not focused on the child's basic needs. Look at the children's faces and you will see the whole of Israeli society."
How would you characterize their behavior?
Spitzer: "We get children who have a hard time behaving properly, who do not accept limits, who injure themselves and others. They have outbursts of anger and violence, they are depressed, anxious, anorexic, psychotic - children whose power of reality is flawed and who are prone to hallucinations. There is a high percentage of children with acute attention deficit disorders and problems involving deficient emotional, sensory or behavioral adjustment."
A child who suffers from emotional adjustment problems, Spitzer explains, shifts rapidly from laughter to crying, from happiness to glumness, from anger to pleasure. Disorders related to sensation are manifested by a lack of awareness of the senses: For example, a child might think he is touching someone gently whereas in reality his physical contact with others is strong and violent.
Children who suffer from movement-related deficiencies are unable to stop themselves from doing certain things. "These are children who run wild, at first with enjoyment, but who cannot be restrained and for whom limits must be set for their own protection. They are constantly running into objects and experience a high level of risk," Spitzer explains, adding that another problem among the children involves improper behavioral responses. "A child who gets angry is able to stop and restrain himself, but a child with such a deficit will immediately burst out at whoever happens to be next to him, hit them and behave aggressively."
Do you feel that the problem has been aggravated in recent years and that more children are being referred to your unit?
What is the reason for this?
"There are several reasons. First, there are social problems. People are more concerned about making a living, about material needs and status, and have less time for their children. In addition, our society has become more alienated, and this affects the way children grow up. Another factor is that obstetric medicine has developed and there are now more high-risk pregnancies, so children are born and survive, but because of the difficult circumstances of their birth they will potentially suffer from developmental problems and problems of sensory or behavioral adjustment. If the parents lack the knowledge and understanding required in such cases, you get a snowball effect."
Coming to terms
Yair is four years and nine months old. Last September he started his second year in the Flower Kindergarten. He suffers from emotional, communication and behavioral problems, as well as attention deficit disorder, and is prone to outbursts of violence. It was only here that his parents, Noa and Tomer, received an accurate diagnosis of his condition. The parents, both of whom hold master's degrees, relate that for a long time they had felt utterly helpless.
"We enrolled him in a special-education kindergarten at Sheba Medical Center, but even after a year, they were unable to diagnose the problem accurately," Noa says. "The fact that there was no appropriate solution for dealing with the complexity of his condition left us deeply frustrated."
Then Noa discovered the Geha unit. "I got here through the Internet," she says, "but at first I had to overcome a mental barrier: I was afraid to enroll our son here because the facility is located in a hospital for the mentally ill, and because of the other kids at the kindergarten. I was concerned that the atmosphere would affect him adversely."
Noa and Tomer decided to visit the unit beforehand and, "We saw immediately that the senior psychiatrists, despite their vast knowledge, spoke and dealt with us at 'eye level' - with us and not above us." Immediately upon Yair's enrollment in the kindergarten, at the age of three years and 10 months, it was decided to treat him with Risperdal, an antipsychotic drug.
"At first I was very much against it, but I went through a process within myself," Noa explains. "In the first stage my cooperation was only mechanical. But gradually I saw that the boy was developing and I told myself, 'I don't care what he is taking, the main thing is not to deprive him of treatment.' It's like when someone has a problem with his sight - obviously he will wear glasses."
How is he now?
Noa: "There has been a tremendous improvement since he's been here. For example, it used to be that every trip in the car with him was a catastrophe. He would go wild and strike out with his hands and feet, crying and screaming. I had to hold him down while driving. That's rare today."
Tomer: "In both summer and winter we had to keep the windows closed at home, because he liked to throw things out the window. That hardly ever happens now."
According to Noa, "Yair's sensory faculties have improved and so has his behavior, but above all there is a pleasant environment where he feels a desire and need to learn - which in the past did not exist at all. It was always as though something was afflicting him; no one understood him. But the medicine helps him adjust to a large number of situations, the speech therapy and occupational therapy help and the work of the staff along with the tools we have acquired are beginning to have an effect. We feel it is a privilege that he is here."
According to Noa Ofer, director of Geha's Educational Center, of which Flower Kindergarten is a part: "Many parents want to enroll their children here when they see the investment and understand the scope of the comprehensive treatment that is offered. But I explain that the condition of acceptance to Flower Kindergarten is [the need for] hospitalization. This is a hospital first, and the people who make the decisions on whom to admit are the psychiatrists."
Noa and Tomer chose not to hide their son's condition. "We know there are parents who conceal such things from those around them and from their extended family, but we feel we have nothing to be ashamed of," Tomer notes. "Friends, neighbors, family - everyone knows and everyone accepts it. No one has ever said anything." Nevertheless, Spitzer notes that it is not easy for some parents to cope with social stigmas even before they have seen the facility; they are simply wary of going there for a diagnosis. "Parents sometimes think that if a psychiatrist will see the child, she will certainly give him medication. That is absolutely not so - only a third of the children here are treated with psychiatric drugs. Sometimes, in fact, parents insist that we administer such medication because this was recommended by another institution, but I say, 'Hold on a minute, I will diagnose the child first and see what the problem is.'"
Is there public ignorance about the phenomena you deal with?
Dr. Miriam Peskin: "Yes. There are parents who go from one institution to another, see countless doctors and lose time until they get here, because they had no idea the place exists and can diagnose and treat the child. Even doctors in the system, experts in ADHD [attention deficit hyperactivity disorder], sometimes display ignorance. They are often capable of telling parents that ADHD cannot be diagnosed before a child starts school. Yet one of the characteristics of the disorder is that it develops before the age of seven. In other words, the last thing we need is to identify the disorder and treat it when the child is already in first grade. Such ignorance exists at every level."
To what extent does the stigma deter parents from coming to you for treatment?
Dr. Ruth Baruch-Movshovitz: "We see parents who repress things. They don't want to acknowledge the fact that their child needs to enter this kind of framework and may even require medication. It sometimes reaches an extreme when [people in] the parents' surroundings ultimately force them to cope: for example, teachers who tell the parents that their child can no longer attend the kindergarten. In many cases the parents shrug it off and say, 'Well, the kid is a bit mischievous - what of it?' They reject criticism of the child."
Don't the parents see that the child is in distress?
"Parents do not always perceive their child to be suffering. They see him going around and hitting everyone, but it is difficult for them to take in the fact that the child's inner experience is not one of strength, but of distress. After all, a very young child will not go around hitting children in nursery school just like that. As specialists we know that there are no bad children, only children for whom things are bad."
What do the parents feel when they grasp their child's condition?
"Guilt, anger, frustration, a sense of loss, mourning. They have to digest the fact that their child is not only different, but that this is something that will affect his whole life. Once they do, they undergo a very long process of mourning, and only afterward, acceptance."
The animal-petting corner of Geha Mental Health Center, which is located not far from Flower Kindergarten, is a therapeutic site. It houses about 30 tranquil denizens: rabbits, ducks, guinea pigs, cats, turtles, parrots, hamsters and goats. There is also a large cage for birds which people can enter, and a pond in which goldfish swim contentedly. Inge Mintz, who established the corner 15 years ago, says she has found that children with problems of communication have a great affinity for water.
Sitting in her country-style hut while a goat, a cat and a rabbit eat from different troughs, Mintz, who was born in Holland, says that after retiring from a career as a biologist she wanted to work with animals and people.
"I noticed that the animal-human connection has a good influence on the psyche," she says. "But everywhere I went the idea was rejected. I was told that to raise animals on the grounds of a hospital was not hygienic and would spread disease, that it was an impossible combination. But Prof. Spitzer loved the idea. Now I get college students from all over the country who want to learn and to specialize here."
A session of animal assisted therapy lasts 45 minutes and is confined to one child. Now it's Yair's turn, Noa and Tomer's son. He scampers about wildly, picks up the rabbits' water trough and spills it, laughing all the time. The animals flee. Mintz watches him but says nothing, only refills the trough. Yair spills it again.
"Come and see how I put water in the trough," Mintz says. Yair again splashes water every which way, creating a muddy puddle, but this time he himself refills the trough.
How does treatment proceed?
Mintz: "I adjust myself to the child. At this age the child already knows what his needs are, where his difficulties lie and what is important to him - far more so than we realize. I give him a free hand to wander about and observe what he is undergoing, and at the same time, see how he interacts with the animals. The aim is to instill confidence and let him be what he is - that is the heart of the matter."
Mintz emphasizes that phrases like "bad boy" or "bad girl" and "Don't do that" are banned here.
"These are children who are used to being told off and hear talk like that all the time," she notes. "So in order to modify their behavior we need to forge new communication with them, not strengthen the stigma. What characterizes the treatment of these children is acceptance. I do not try to extricate a depressed child from his mood. He can be in that mood and I accept that. It's from that place that I help him."
What is the basic idea of animal assisted therapy?
"The connection between a child and an animal is a kind of game, in which the child expresses and releases emotions, and the animals accept the children as they are. They are undemanding and noncritical, and that is already a good start. They do not want to change the children - they accept them as they are. When a child encounters behavior like this he feels wanted, gains confidence and returns love."
A similar psychological mechanism is at work in the kindergarten. "When a child in a regular kindergarten runs wild and shouts," says Rina Seltzer, who has been a kindergarten teacher here for the past 16 years, "he is made to leave the room or stand in the corner. But that isolation intensifies his non-learning. So that is not a useful method; it is impossible to get to the child and integrate him like that. I do the opposite: I do not remove anyone. Even if a child runs wild, he stays in the room. So then it's not worth his while to behave like that. In contrast, when they behave well I compliment them or give them a little present. And then they see that not only does it not pay them to run wild, but that good behavior earns them a reward."
Activity in the kindergarten is based on many creative elements. In a random visit I see a boy playing a computer game in deep concentration, a small group listening to a story and others painting as Seltzer sits among them. Spitzer says she believes in the healing power of the arts, of expression and of creative thinking. Noa Ofer adds that she strives to allow the youngsters to experience everything that is taught in regular kindergartens - an approach that is not self-evident when it comes to a place like Flower Kindergarten.
"We were criticized when we started to hold Remembrance Day and Holocaust Day ceremonies," Ofer explains. "People asked why we were doing that with children who are already depressed. I replied, 'Excuse me, but these days appear on the calendar and the ceremonies are held in every regular kindergarten and school - the children will cope.' We should not make light of their inner fortitude. And you should see: They write, read and take part very willingly - it's impressive."
The main problem, Seltzer says, is not coping with what goes on in the kindergarten, but the situation in the children's homes. "A child comes here in the morning and says, 'Since I left here yesterday I didn't eat. Mom didn't give me food.' So you send him home with a sandwich, but the next day his mother sends the sandwich back, because she denies having starved him. And at the end of the day, when he goes home, you ask yourself whether he will have anything to eat that evening. That is the hardest thing we have to cope with: seeing the children in dire straits of emotional or physical neglect."
Living with frustration
At noon, Yitzhak Shahar, the kindergarten's caregiver-nurse, prepares the cart of psychiatric drugs. He takes the Ritalin tablets from a locked drawer.
"It's considered a controlled substance under the law and must be kept locked up, and every use has to be reported," he notes. He prepares precise dosages, which he places next to the names of the children on a list. He then enters, reads out names and gives the children the medicines, which they take with their lunch. Shahar writes a medical follow-up report for each child every day.
"The report is essential," he explains. "My role is not only to record the medicine and distribute it, but also to monitor its effect on the child. Has there been a change in his behavior? Are there side effects? The job is not only technical, but also includes observation."
Can achievements be arrived at in this treatment?
Shahar: "I believe that everything begins and ends with the parents. I am not talking about children with organic problems, who in scientific terms, as we know, can only go so far. I am talking about children who possess fantastic capabilities - leadership, perception, sensitivity - who are in this condition because of their parents. For example, a child who wants to go home to Dad all the time, but whose father flees every time the child needs him. What do you think the effect is on the child?"
He admits that "the hardest thing is to live with the frustration when you see a child with whom you can do excellent work, but the parents, in contrast, are incapable of doing anything. You can talk all you want and provide tools, but in the end the father asks, 'Okay, so what can I do about it?'"
The arsenal of psychiatric medication is limited for children of this age, and divided into three main groups. The first and most frequent is the group of "stimulants." These drugs, in which the active element is methylphenidate, include the various types of Ritalin and Concerta. They can be administered to children over the age of five with the authorization of the Ministry of Health. The second group - antipsychotic medication - includes Risperdal and Neuleptil. In the treatment of children their effect is to reduce aggression and disquiet, treat movement-related and behavioral problems and tone down hyperactivity. Even though there is no age limit in their prescription, they are infrequently dispensed at the kindergarten. The third group consists of drugs that counter depression and anxiety, such as Prozac. Ruth Baruch-Movshovitz is a passionate defender of medication.
"The results are amazing," she says, "especially with Ritalin and Risperdal. For the child, they sometimes make a difference of night and day."
But isn't their use accompanied by social stigmas?
Baruch-Movshovitz: "Yes. If you tell people that Prozac is administered to children, they will be quite astonished. And if you say you are giving them Ritalin, people will say you are drugging them. But there are all kinds of stigmas and counter-agendas that miss the main thing - namely, that this is not the first choice in our treatment and that we choose it only in cases where it can change a child's life."
In what way?
"The most critical factor - and this is common to all the children here - is the question of what effect the children's difficulties have on their self-image. It is at these ages that one's self-image is fixed. If a child feels that people are always angry at him, that is his experience of the world and it will accompany him for years afterward. It is nothing short of dramatic. The ability to modify this is not necessarily by means of medication, but psychiatric drugs are part of the therapeutic package for the children. With the right diagnosis, the right timing and certainly after previous treatments which didn't succeed - such treatment can in most cases change the child's prognosis."
Is it true that children who need Ritalin at this age and do not get it, are liable to react by resorting to substance abuse later?
"As far as I understand, the answer is yes. We see that their body craves particular substance that makes them alert and sharp. Some of the attention deficit and hyperactivity problems are alertness disorders. Children like that move about all the time, because their brain is fighting to be alert. Drugs like cocaine, for example, stimulate a similar effect. There are impressive, accepted studies showing that children and adolescents who were not treated medicinally have a greater tendency toward drugs during maturation and adulthood."
Six-year-old Yotam is one of the children whose life was changed by Ritalin. "When he was two, I noticed that something was wrong," says his mother, Michal, 37, an economist. "It was clear he had difficulties walking and listening; he didn't speak but only mumbled. Obviously, something was wrong."
Yotam was born with an organic problem. He was sent to a special-education kindergarten in the community, but his mother felt that wasn't enough.
"The staff there was frustrated," she recalls. "They put a lot of time and energy into him, but without getting results. The attention deficit disorder was serious, and it was hard for those around to cope with him."
Michal heard about Flower Kindergarten, but was wary of it. "I was afraid of the stereotype," she admits. "Yotam does not have mental problems, and I was afraid that placing him in an environment with children who do would only aggravate his condition."
Michal went to a private psychiatrist, who recommended Neuleptil, a tranquilizer. "There was improvement at first, but after a few weeks I noticed that it was causing an aggravation of the symptoms. For three months I visited psychiatrists, neurologists and physicians. Each of them suggested something else. Those were very hard times, until I got to Geha. There they provided an exact diagnosis and a comprehensive answer to all the conditions and disabilities."
After a year in Flower Kindergarten Yotam returned to a regular kindergarten. Placing him in Geha was "the most significant thing I ever did in my life," Michal says today.
What made the difference?
Michal: "He started to take Ritalin, which stabilized him, and along with the warmth of the staff and the professional care, a significant change occurred."
Weren't you afraid to give him Ritalin at the age of five?
"I wasn't afraid because I was feeling helpless. During the year in which he attended the kindergarten, he was calm, relaxed, a boy with joie de vivre, and his social interaction was also good. I had moments of satisfaction from him, which I'd never had before. Nowadays I am giving him Concerta. Sometimes I feel a twinge when I give it to him, and I wish I didn't have to, but he needs it. I have no doubts. There was one day when he spat out the pill ... You saw the difference: He was restless, threw things at other children and no one wanted to sit next to him. That strengthened my resolve to not feel guilty. I say to every parent who is undecided and has a child with very serious attention deficit disorder: Give him the medicine, because it creates a revolution - a change for the better in the child himself and in the home."
In conversations with the kindergarten's professional staff, one hears time and again that the key to change in a child's emotional state lies with the parents. That is the motto of this facility, and much of the work done there centers around parent-child relations.
"We help the parents to 'think' the child - to understand his needs, his motives, the inner world that preoccupies him, why he is behaving this way," explains Baruch-Movshovitz. "Our role is to orient the parent, show him the child's difficulties and needs. We do not give the parents psychological treatment; we have no mandate for that. But we do deal with parenting. So, sometimes we will talk with the parent about his inner world, in order to understand where he is coming from and help him understand where his parenting sprang from, with the intention of helping him to change patterns of behavior."
Dana, 32, epitomizes the situation in which some parents undergo profound, parallel processes along with their children. When her eldest son was two, she relates, his behavior underwent a change.
"Until then he was a quiet boy, and suddenly he developed attention deficit disorder, rage attacks, crying that never stopped over every little thing, a lack of social skills, disquiet, violence. One day he actually cut a child's throat - fortunately a disaster was averted because he used a blunt tool," she says.
Her son's problem is organic and congenital, but was aggravated by emotional factors. Dana admits that part of the reason for this was that her own father was physically violent to her, and she copied this pattern of behavior in her relations with her son.
"I got to a place where I would slap him or scream at him, because I didn't have the tools to deal with his condition, and that only made things worse," she admits.
She and her husband at first denied their son's serious condition. "We didn't want to know, we shut our eyes. 'The kid is perfectly fine,' we said, 'so why is he being picked on?' When we were told we should place the boy in the Geha kindergarten, my husband was very much against it. Even after a regular kindergarten refused to accept him, and the Psychological Services pressed us to give him real therapy."
Finally, after they observed a further deterioration in their son's condition, the parents revised their approach, and grasped that the child was in genuine distress. Dana relates that she too was afraid to place her son in a kindergarten located in Geha Mental Health Center, because of the stigma. Today, though, she is sorry she did not take that step sooner. Her son was enrolled three days a week in a regular kindergarten in the community and two days a week in Geha. After a year, he now attends first grade in a regular school. Dana is proud to relate that he is getting praise from the teachers and plunges enthusiastically into his homework every day.
"During his period in Flower Kindergarten, I learned many tools for coping with him," she says. "I was taught how to approach him, how to calm him at moments of crisis and how to avoid being furious with him. My husband and I also went to [parenting] courses at the Adler Institute."
Not long ago, Dana herself went for an evaluation and was found to be suffering from attention deficit disorder.
"I started taking Concerta myself," she says, "and I am now calmer and more focused. I cannot avoid thinking that if I had been diagnosed at a young age and treated, my life would look different." W
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