When twins Haggai and Galit (all names in this article are fictitious) were a year and a half old, their mother, Ronit, realized that they were late in walking and that their speech was also not developing as it should. She took them to a center for childhood development, where she was promised that the children would undergo speech and other types of therapy.
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At the age of three, however, Haggai could only say one thing: “Ah.” Galit, too, had speech difficulties. Ronit took the twins to a psychiatrist, whose diagnosis was that they were autistic.
“When a crisis hits me, I first of all deal with it and then allow myself to go to pieces,” Ronit recalls. “I was in maximal functioning mode: Within three months we organized the National Insurance allowance, registered with Alut [Israeli Society for Autistic Children], read everything we could, and placed the children in a diagnostic preschool, where they spent a year. There was one day when I opened the window and screamed, ‘What did I do to deserve this?’ But even on the darkest days I was able to see the small nuances – something new Haggai did, something else he understood – things that other people barely see. That kept me going.”
At first, Ronit wanted to have the children treated by the applied behavior analysis method, a functional process that stresses functionality and is also referred to as behavior modification, which sometimes produces quick results. But one psychologist recommended a different road. The children are highly intelligent, she said, so they need an approach that goes beyond the functional. She recommended one of the special Shaked preschools – progress would take longer, but the facility would give them what they needed, she added.
Staff at the Holon-based Shaked facilities employ a psychoanalytic-developmental method. Their aim is to forge connections between the possibility of change and development within what is called the autistic child’s inner experience, and his dealings in the outer world – i.e., the ability to manage in society as is expected of him.
“Twice a week for a year, Haggai received emotional care there,” Ronit relates. “In every meeting he crawled under a table and covered himself with cushions. The caregiver sat with him for 45 minutes, her attention fixed on him. After three-quarters of an hour, he finally stuck out a finger. It was if he’d been reborn.”
Once a month, Ronit and her husband attended a parental guidance session at the original Shaked preschool in Holon. “It helps you understand the child, be less frustrated and shape your parenting accordingly: to accept the child you have, not the one you dreamed of. The work in the preschool trickles down into every activity. For example, a request to pass the salt becomes an opportunity to teach social interaction. Sending them there was a very smart decision.”
Galit and Haggai are now in high school. Galit is in a regular class, and Haggai’s in a special one.
“I was lucky,” their mother says. “The organic damage my kids have suffered is apparently not severe. Every child has different conditions of development. But those with the patience to pursue this journey – which is life long – will see results.”
Shaked preschools are among the oldest in Israel for treatment of children with disorders on the autistic spectrum. Its founders grasped that such individuals are incapable of integrating into different realms – for example, they perceive no connection between their experiences outside, in the yard, and those inside the kindergarten a moment before. Thus, close cooperation is needed between the facility’s different staff members. The dialogue between the professionals who work with the children is facilitated by a psychodynamic therapist, all of them with the infinite patience required to cope with slow progress, sometimes lasting months or even years.
Shaked staffers have been on this long night’s journey into day for the past 22 years. Now they have set forth their credo in a book (in Hebrew), co-authored by the whole staff: “I Do Not Move, Don’t You Move,” subtitled “A multidisciplinary intervention with young children on the autistic spectrum.”
It features articles on understanding autism, on the facility’s distinctive working methods, on case histories written from different professional perspectives and more. There are also discussions of toilet training and of the impact of autism on parenting. The book is intended for therapists and parents alike.
Shaked originally came into being after parents of autistic children in Holon approached an association for at-risk children, which operated in the mental health clinic of Ramat Chen, a neighborhood in Ramat Gan.
“At the time, all the preschools for autistic children were affiliated with clinics and hospitals. These parents wanted to open a first preschool in the community, for their children,” says Pam Yogev-Platek, a clinical psychologist and the director of therapy at Shaked since its inception. The facility operates in conjunction with the association, the Health Ministry, the Education Ministry and the Holon Municipality.
Yogev-Platek was joined early on by Tami Pollak, a clinical social worker, who also edited the new book. Pollak’s years of work at Shaked – where she is coordinator of multidisciplinary studies, among other tasks – also prompted her to do a Ph.D. in the metapsychology of the developing body.
“The beginning was difficult,” Yogev-Platek relates. “We didn’t understand a large part of the children’s behavior. Our knowledge of autism was fragmentary. The behavioral approach had begun to develop: stimulus, response and reward or punishment. We refined it over the years, but the main point is that the motivation comes from the outside. We chose the developmental approach, which believes that these children have something inside that we want to awaken.
“For a regular child, development is self-evident. With autistic children, initiative is necessary,” she says, adding that the youngsters themselves be taught and encouraged to take initiative themselves. “We combine psychoanalytic methods and a behavioral approach. We created an educational-therapeutic model that makes this feasible.”
The Shaked preschool Haaretz visited is made up of old prefab structures built around a courtyard in a residential neighborhood. The compound has two locked gates, to ensure that children do not leave the premises, but the yard exudes a friendly atmosphere. There are three classes and a treatment center with rooms for psychotherapy, occupational therapy, communication clinicians, physiotherapy and parent-child encounters. There are eight children in each class, and 35 staff members.
“Our model operates in several circles,” Yogev-Platek explains. “The inner one is the child’s mental world; the outer one is external reality – preschool and family. In the innermost circle, the psychotherapist is attentive to every hidden nuance related to the child. In each circle, progressing outward, there is less personal adaptation and more of a demand that the child adapt himself to reality. The second circle consists of individual paramedical treatments, the third of group treatment with the participation of the educational team. The outermost circle is the preschool and the child’s day-to-day family experience.”
Each expert working at Shaked receives weekly professional guidance and psychodynamic instruction from a psychologist. The staff holds a weekly meeting, discussing a different child each time. There is also another weekly gathering, to discuss theoretical materials about autism and child development.
Another unusual aspect of the facility is the input it receives from assistants – a number of women, mostly hired by means of employment agencies, via the municipality. They have no professional training and are paid low salaries, yet they are constantly with the children, some of whom are seriously disabled, helping them with the most basic bodily functions.
“It’s impossible to explain how hard these women work and how important it is for us to invest in them,” says social worker Pollak. “They take part in the staff meetings that discuss the children. There is no such thing as us talking about dealing with the children without the assistants taking part.”
The button boy
For the past eight years, Shaked has run a special weekly program in which each of the non-professional female assistants works with a child and an instructor, and receives personal instruction and guidance.
“It’s a huge investment, but the impact is tremendous, both for the children and for the assistants. It gives the women the feeling that their work has value,” Pollak notes.
The Sisyphean, almost incomprehensibly slow process of drawing out some children is exemplified in an article in Pollak’s book about a boy she calls Adam. Severely disabled, Adam came to Shaked clutching a beloved object: a small, ordinary shell button that he held up in front of his eyes to try to catch the sun’s glint. He did this for hours, oblivious of the world around him. He did not speak and was unable to function in any normal way.
“He was seemingly not interested in anything,” Pollak recalls. “If we tend to think of autistic people as not returning a glance, he had completely blocked his field of vision.”
The first time Adam entered the treatment room, he sat down on a chair and threw himself backward. “By a miracle I managed to catch him – he could have broken his neck,” Pollak remembers.
“Think about this in terms of communication,” she continues. “On the one hand, the child seems not to notice my existence; on the other, he places himself in my hands completely, and I absolutely must not take my eyes off him for an instant. It’s the same with many autistic children: They don’t see you, but are totally dependent on you, both functionally and – even more – psychologically.”
The initial therapeutic goal with a child like this, Pollak explains, “is ‘only’ to move the button aside – to get him to look at something else. But that requires a substantive change in his psychic structure.”
It was like an endless negotiation process: In one case, the assistant succeeded in moving the button away for a second – but it immediately returned to its place.
“For the first year the effort was made entirely by the adults,” Pollak relates. “A way had to be found that would allow Adam to be involved in everyday situations, in which he would still hold the button but without letting it block everything. In the group framework, the assistant and the caregiver had to make an infinite effort to get him even to see a slice of bread before it entered his mouth. The team effort is crucial here, because who can deal alone with the anger that’s generated [by such an experience] or with the mechanisms of disconnect that spring into action unconsciously, over and over?”
In the second year, Adam walked around with his little finger curled around the button. One day, he started to point with the hand that was holding the button – significant progress, attesting to communicative development. Then, one day he took a sheet of paper, placed the button on it and started to draw circles around it with a pencil.
“A circle is a favorite autistic shape, because it has no beginning and no end, it’s all totally one,” Pollak explains. “He circles the button with a pencil: He and the pencil and the button are one. I was frightened at first – again something endless.”
This went on for a long time, until the day came when Adam tried to stick the pencil into the button’s holes.
Pollak: “You can’t imagine how delighted I was at this simple act. ‘Eyes?’ I asked him. He drew the line of a mouth below. It wasn’t the fact that he managed to draw a face that delighted me. It was that he was capable of realizing the fact that objects in the world are complex and possess a structure. He grasped that drawing something does not express the thing itself, but is the representation of something at the symbolic level.”
That was a giant leap forward. A few months later, Adam noticed the crack under a door for the first time, slipped the button through it, and opened the door to rediscover it. After four years at Shaked, he was speaking and moved to a special-education school.
“He’s still very autistic,” Pollak explains, “but he is communicative, he’s alive, he’s happy, and his mother and father are having a very different parenting experience.”
Sometimes, she says in conclusion, “I find it hard to fall asleep at night, because of all the details I have to keep in my head. But a very important element of autism is the desire to freeze and suspend things – time, place, development. Precisely because of that, it’s always urgent to introduce innovations in thought and therapy.”