In addition to the educational institutions I visited this past month I also had the opportunity to see two psychiatric hospitals and two early intervention services in the Porto region.
The Hospitals:
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Hospital de Magalhães Lemos (Porto): This psychiatric hospital recently underwent a merger with a couple of other hospitals in the area, and is one of 3 with pediatric units. It is clearly betting on the full social integration of individuals with mental illness. The psychologists act as liaisons with the Health Centers and other General Hospitals, as well as the structures of social security, public and private, and the municipalities in the Porto region. The pediatric unit serves children ages 4 months to 12 years-old. The lead psychologist reported that the services are more disjointed since they were removed from the pediatric hospital. The majority of the cases seen are for custody cases, referred by pediatricians.
I observed an IQ assessment for a referral where the child was being oppositional with her father following a divorce. I was struck by the mismatch between the referral question and assessment procedures. The WISC-III was used, as I was told that the WISC-IV is still being translated/ validated. For this 7-year-old girl, a photocopies protocol was used, the girl was sitting in a chair that was very tall, behind a desk that was too high, and was forced to sit sideways to allow for space for her feet. The girl was constantly shifting in her seat as well as standing throughout the session in order to remain physically conformable (this was clearly not due to inattention). The administration was not standardized, for example, on the Picture Completion subtest, the clinician said, “this is a picture of a pencil, in this pencil, what is missing?” Strategies were also given to the child (e.g., counting, on the Information subtest). In addition, the protocol was laid in front of the child, so that she could clearly see each positive and negative strike toward her score. The rationale I was given for this was because, “if you don’t let them see, they think you are hiding something from them.” The other children scheduled for the day did not show for their appointments.
In the afternoon I sat in on Grand Rounds for the pediatric psychology section. Each psychologist presented cases they found difficult, and received feedback from the other professionals. It appeared to work well, though I believe more time could have been allocated to problem-solving, opposed to case presentation.
2) Hospital de São João (Porto): The psychiatric unit at São João appeared much better organized and effective than Magalhães Lemos. It is comprised of four sections: (1) general consultation (which includes immigration services), (2) day hospital & community psychiatry, (3) psychosomatic/inter-consultation (other departments, (4) youth & family services. The latter (4) –youth and family services, provides general psychiatric services until age 25, and specializes in eating disorders, early onset psychosis, and parent-training. The ‘team’ is comprised of 2 Adult Psychiatrists, 3 Pediatric Psychiatrists, 2 Psychologists, 1 Occupational Therapist, and 1 Social Worker. Both the psychologists and psychiatrists do consultations, while the psychologists focus mainly on competency and phobia interventions.
The main modalities of intervention include psycho drama, dance therapy, and family therapy (the first two are the main focus of eating disorder interventions). In the early psychosis groups, family therapy is undergone once-per-month in a group meeting.
In visiting the units, I not only met and spoke to the doctors, but had the opportunity (though unscheduled) to meet and talk with the patients. While waiting for a trip to the next unit, we waited in a coffee bar –frequented by the adult patients. One patient, who said she had Schizophrenia and had recently suffered a drug-induced psychotic break, said that she found the services at the hospital infrequent and inadequate, and said that she had been seeing a psychologist (for therapy) in a private clinic for years, and only went to the hospital to see her psychiatrist for drug titration. She said that the two doctors/institutions did not communicate, and she felt like she was “slipping through the cracks”. We also spoke to a psychiatrist with a university appointment in the department of nutrition, who spoke to use about hospital-based research. He explained that there is an Institutional Review Board for ethics, but that it is very complicated and time consuming, and that most times the practitioners conduct the research, and ask for permission after. He said that the doctors use their respective ‘internal moral compasses’ to tell them what it right/wrong. While I do believe that some of the ethics boards procedures are extensive, they are necessary, and something that should continue to be developed in Portugal.
The Clinics:
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ANIP (Coimbra): Is the National Early Intervention Association (ANIP), which works in collaboration with regional health, education, and social security agencies. They are working with the Coimbra Project “Integrated Project for Early Intervention (PIIP), on which the National model was based. The early intervention practice is based on trans-disciplinary (though it sounded more like inter-disciplinary) teamwork, use of existing resources, and family-centered interventions. Through annual trainings held at the national level, as well as conferences, and resource dissemination (e.g., lending library, mailed pamphlets) the association provides training, information, and support for professionals and families involved in the early intervention process. It all started with the Coimbra project in 1989, was put into legislation in 1999, and was implemented as a law in 2009 (Law No. 281/2009).
The general aims of the PIIP project are to help families with children ages 0-6 years with disability or those who are at risk for developmental delay. The project is structured on an ecological model (á la Bronfenbrenner), with the Coordination team (physician, social worker, speech therapist, nurse, psychologist, and physical therapist) communicating with four teams (administration, supervision, training, and technical) who all communicate with five smaller service-delivery ‘supervision’ teams that each provide services to various districts (based on population size and number of professionals). The philosophy of the project is to deliver services: (1) from an ecological perspective, (2) that are family-centered and home-based, (3) strengths-based, (4) relationship-based, (5) facilitate communication between service providers, (6) are self-evaluative.
Their tag-line is “enabling and empowering families”, and I think it is truly wonderful to perpetuate the belief that all families are competent to aid in habilitation, especially on a National platform! Within the child, the teams focus on increasing abilities and monitoring development. For families, the project leaders strive to promote autonomy of the child and family unit, as well as the family’s involvement in the intervention process, and improve the family’s dynamics within their daily routines. Community-level involvement works to promote communication between service-providers, and creating access to resources. The intervention is six-pronged: (1) relationship-building, (2) input and decision-making, (3) competency-promoting, (4) parents as adult learners, (5) informal support for families, and (60 informal supports for professionals.
While the efficacy of the PIIP project is still unknown, it has been highly effective in the district of Coimbra, and I truly hope that it works for the whole of Portugal –what a wonderful program!
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UADIP (Porto): A center for Developmental Evaluation and Early Intervention (UADIP: Unidade de Avaliação do Desenvolvimento e Intervenção Precoce), they serve children ages birth to six-years-old, from the district around Porto. In conjunction with community services, they provide evaluation for children at-risk for or with developmental disturbances. Their teams are comprised of psychologists, social workers, physical therapists, speech therapists, occupational therapist, and a special education teacher. They base their practice on Transactional Theory: the interplay between the child and the environment. The team uses objectives that provide conjunctive training and common intervention strategies, in which the families are highly involved. Specifically, the family is trained on interaction styles and the necessitated intensity of the intervention (it is important to UADIP that intensity is not as important as functionality of intervention).
They work with the families to increase the number and quality of interactions, and increase the knowledge of strengths and weaknesses in the children; all of which is done in contextualized interventions (e.g., in a classroom) at least twice per week. There are two teams: Team A (for younger children, 0-3), and Team B, (for older children, 3-6). Team A, which serves 21 children focuses on high-risk children, as well as habilitation of family. They provide interventions for 3months, re-evaluate, and then re-intervene (if necessary) –no more than 2-3 times. Team B serves 66 children at a time. In the community, children may receive therapy at Maria Ped. (Hospital); Rehabilitation Center of Gaia, or at UADIP for speech intervention in children with Autism Spectrum Disorders. Dependent on the family’s worries, UADIP will perform specialized assessments and/or interventions (e.g., in preschools, or work with schools for transition planning).
While UADIP has two staff psychologists, who are present throughout evaluations, it was unclear as to their role in evaluation/assessment process, other than peripheral functioning. That is to say that UADIP appears to place great emphasis on physical rehabilitation of children (only 1 psychologist per team, compared to 3 occupational therapists, and 2 physical therapists).This was also echoed in the physical structure of the building, with ample space for physical rehabilitation, including multiple Snoezelen sensory rooms (see picture). While I believe these interventions are all valuable, I think that the psychologist could make a greater impact on the children’s developmental trajectory by increase the time and methods used for intervention.
In sum, UADIP provides wonderful evaluation, training, and therapeutic technology services to children in need.
