Rehab centers

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I spent 4 full days at the rehab centers this week, mainly observing the therapists and the teachers at work. It has been fascinating to learn the ins and outs of therapy services children receive here in Turkey. Here’s the scoop:

Rehab centers are for children with a variety of special needs, with a large percentage of the children who attend them diagnosed with Cerebral Palsy, Autism, Mental Retardation, and Learning Disabilities. I also saw a boy with Spina Bifida and a 19 year old with Muscular Dystrophy. Over 500 children total are served by these two rehab centers. There are other places children receive rehabilitation and special education in town as well, such as at the University, the hospital, an orphanage for children with disabilities, a trade school for children with special needs, and special education classrooms at regular schools. Both rehab centers offer individual and group education for children with Special needs. The children are referred to the center by a doctor, who specifies what services the child will receive, and how many hours total the child will receive services. The rehabilitation services are payed for by the government. For example, the doctor specifies that a child receive 12 therapy hours each week, and of what services. The clinicians divide up the alloted hours among the therapy services. I think individualized special ed is included in these hours as well.

Individual special education is given to a child by a special education teacher for 1-2 hours per day. To be a special education teacher a person has to go through a regular (4 year I think) degree program at a University to become a teacher, and then a 5 week, (if I understand correctly due to language barrier) certificate program for special education. Individual special education consists of the following depending on the children’s physical and intellectual abilities: Teaching the children their numbers, colors, letters, grammar, vocabulary, fine motor activities (limited in variety), teaching children some activities of daily living, especially those with Autism, such as using the bathroom, washing their hands and face, brushing their teeth, dressing, manners, socially acceptable behavior, etc. Some of the strategies used to help children learn visual perceptual skills and visual motor skills are similar to those in the US, but a LOT of rote practice is used For example, the children write the letter A over and over again, filling up an entire page with As before moving on to B. V

Group special education consists of 7 students per class, with curriculum set by the ministry of education. This occurs for 3-4 hours per day. These children go home at lunch or stay for other therapies. Psychology teachers work with children who have some behavioral problems or speech problems, and for this reason may not succeed in school. I don’t fully understand the difference between psychology teachers and special education teachers. In therapy and special ed, children are given a blank notebook, which the therapists draw pictures in, draw fill in the blank worksheets by hand, etc for the children. The notebook is sent home with the kids each day so their parents can see what the child worked on in therapy if the parent didn’t attend the session. The parents often attend the sessions for part of the time unless the child behaves badly when the parents are there, which of course also happens. There are some caregiving staff who do crafts and fine motor practice with children in a waiting type of room at one of the rehab centers. I think the kids who attend those session are between therapy sessions and need a place to go. Those caregiving staff don’t have specific training, but often special ed teachers work with kids one on one in that same room for therapy sessions.

Physiotherapy: In both rehab centers there are several physiotherapy rooms and 3-4 physiotherapists who work with children who have physical problems. Their training is similar to the training of physical therapists in the US, although in Turkey, people specify what area of Physical therapy they want to go into early in the program, so the physiotherapists who work with kids will likely always work with kids, because that’s what their training is in. I have spent a lot of time with the physiotherapists at both rehab centers, and I have learned a lot from them. They use some occupational therapy techniques in their treatments, depending on the child’s deficits. They pointed out to me their use of Bobath techniques for younger children with CP. They don’t use functional activities in their therapy however, rarely using targets or toys for the kids during therapy sessions. Therapy is very passive, with lots of passive range of motion being done. Even their version of Bobath therapy is very passive. They don’t have the kids (and occasionally adults with hemiplegia) reaching for objects, etc. I haven’t had a lot of experience watching physical therapists work with children in the US and seeing their techniques, but I think that the handling of children here is much more aggressive, quick, etc. It also of course depends on the therapist. One therapist I saw was moving the arms of the 2 adults with hemiplegia so quickly I was certain it was causing them more shoulder pain. Both of them complained of shoulder pain during the treatment and the aggressive arm movements continued.

For the patients with upper limb problems, fine motor activities are used (stringing beads seems to be the fine motor activity of choice!). For kids who can’t put on their shoes, the physiotherapists encourage independence in this ADL, but don’t specifically target it as part of the therapy. I saw one child who was put in a standing frame after his PT session, and then taken up stairs to do is hour of education while in the standing frame- I thought that was a good use of time, but I wonder about the poor posture he had while in the standing frame. The posture of the kids when seated isn’t attended to like it is in US therapy sessions. The kids who have some difficulty holding a pencil (due to CP spasticity or low tone), are assumed to be unable to do so and therefore aren’t encouraged to write at all- they learn reading and grammar but writing is left out.

A few people have been extra helpful in translating for me and showing me the rehab centers. The psychologist at one of the rehab centers (We’ll call it rehab center #1) is from Albania, majored in psychology and has an incomplete masters degree in philosophy. Her name is Stella. She speaks very good english and I have learned a lot from talking with her. At the other rehab center (we’ll call it rehab center #2), there is a physical therapist from Germany named Jessica who speaks very good English, and who I have also learned a lot from- not only about rehab in Turkey, but in the differences between rehab in Turkey and Europe. European therapy seems to be very similar to US therapy, with the professionals trained in the same kind of techniques and held to similar standards as professionals in the US. Stella taught me that when a child comes for services at the rehab centers, his or her mother fills out a sheet noting all the child’s capabilities including level of independence in ADL skills. I don’t think a formal evaluation is done, but a treatment plan is written for each child and changed according to the child’s improvements or lack of improvement. Jessica said that a couple months ago they started having to write short notes on what treatments were provided each day for the kids. Before this there wasn’t any daily documentation that had to be done. The therapists still don’t write goals or do any standardized testing, which is much different than pediatric therapy in the United states. When talking to Jessica, the physiotherapist from Germany, she told me that because of her training in goal writing in Germany, she keeps goals in her mind and uses these to guide her therapy, but no goals are even written down!

I saw many many children with visual problems. I think this is because a lot of these kids come from the villages surrounding Antalya, and don’t get the corrective eye surgeries they need. I also saw a lot of children with flat heads, due to so much time spent laying on their back. According to the therapists who I’ve been talking with, there is quite a bit of a problem with followthrough of therapy at home, due to the conditions the children live in and the cultural barriers- the following is what I observed and learned from talking with the therapists:

The families of the children are extremely loving, caring, affectionate, and completely absorbed with love for their children. Because of this, they often don’t take their kids out in public because they don’t want people to tease them or their kids, or look down upon their child, themselves, or their family. They also continue to help their children with self care tasks even as the children grow up. If the child has difficulty with feeding him or herself, the parent will feed him or her out of love, so he or she won’t struggle. The same thing goes for dressing and other ADLs. The parents don’t encourage the children to sit up at home despite therapist recommendations, because this takes lots of time and hands on therapy that the parents don’t have- they are busy being a parent and meeting the kids basic needs, maintaining a household, and giving the kids love- not therapy. At the center, I saw a lack of children interacting with other children. May of the kids don’t even express an interest in other children. Some kids are just now learning the basics of appropriate interaction with other kids. It really interesting to watch! This delay in social skills is likely because all the kids know is their homes. Over time, the lack of stimulation, the lack of separation from their parents, and the lack of training in their independent skills causes these children to have even more severe problems. Separation from their mothers for therapy causes them to cry throughout the entire session. They refuse to do things they don’t want to do, because they have not been given consistent and firm limits to their behavior. They have poor fine motor skills and a decreased desire to play. They may not know to feed themselves, dress themselves put on their clothes, toilet, etc because they have never been trained- even into the gradeschool years. Many of the children haven’t started receiving therapy until their problems have become severe and these habits have been ingrained. Their vision is horrible because it was not fixed early on- which contributes to their overall impairments in cognition, motor skills, communication, etc. Early intervention was not an option for many of the older kids due to the only recent advances in therapy services for the developmentally disabled in the past few years. Some of the children’s deficits result from their severe disabilities. Some of it is because of the lack of intervention, and some of it is because despite recommendations to parents by therapists after therapy sessions on behavior management, encouraging independence, etc, the parents continue to do help their kids. It’s easier, it shows the kids they are loved, and it is culturally acceptable. Gaining a better understanding about how the culture is, the family structures, and the overall situation for these families of kids with disabilities, makes these childrens’ conditions more understandable. Many of the therapists have been trained in western ways- with therapy techniques influenced largely by western middle class society. This clash in cultures contributes to the of lack of followthrough of therapy into the home and the community.

I began a parent group at Rehab center #2 on Weds, with two translators who have limited English abilities. I was brought to a room and helped set up chairs for parents to come- pretty soon I had a room full of about 8 parents. Before I even had a chance to tell them that I wanted to hear their questions on how they can deal with their kids and help their kids at home, a grandmother of a child started telling me her story. One by one through two translators who eagerly tried to explain to me what the parents were saying (maybe 25% of my questions and their answers were translated!), the parents told me their situations with their kids, what problems their kids had- they were so eager and wanting to share- they all patiently waited their turn to tell me about their kids. It was so special to hear their stories I just felt like if anything, it was therapeutic for them to be able to talk about it. It was a humbling experience for me and made me more aware that the answers for the parents are not simple, if there are answers at all. I went into the group thinking I would learn their questions, go home and research the answers, and then come back with a list of things they could do to help their kids learn to dress themselves, feed themselves, manage their behavior, etc. Instead I was reminded on the value of just listening and showing that I care, even if they don’t come up with questions for me and if I don’t ever come up with answers. Wednesday, I didn’t provide any information at all, and I don’t even know if I will, but these ladies, with their headscarves and tired looking faces, seemed desparate just to talk- to tell me their stories and have someone nod their head and just listen.

My thoughts on these parent groups, after learning the situation at the Rehab centers more, the cultural differences of many of the families, and engaging with one group of parents, is that it may be more of a support group format. OTs lead support groups right?! Anyway, I hope to be able to answer some of their questions in a culturally sensitive way, and I hope to be able to facilitate some discussion among parents also, so maybe they can give each other ideas and be a support to each other. Mostly I hope that the parents will feel valued, loved, understood, and not judged. They love their kids so so much.

One lady I met today at Rehab center #1, had a cute little kid (grandson I think) who was very interactive and talkative. He told me he could speak in English, although I think he maybe said one word. Then as the PT did Range of motion on his leg, he sang me a song in Turkish. The therapists had explained to his mother, or grandmother, why I was here. She looked at me in her Islamic dress and said Thank you, God bless you. She was so sincere. Later she went out and bought the therapists, including me a bottle of cold water. It is so wonderful to meet such wonderful and loving people. I am amazed at how sincere, how kind, and how welcoming they are to me.

Another thing I’ve learned this week is some Turkish language. Each day I learn more. At the school I learn vocabulary, grammar, and expressions just like the children! I feel like I’ve been completely immersed in the culture and the language. Maybe by the end of the summer I’ll be speaking good enough Turkish to be able to translate for myself! Or at least have a conversation with a kid. =). I am excited to spend more time with the therapists, teachers, children and parents and get to know them more.

The volunteer team from Seattle comes next week! They will be doing a project in a preschool here. I'm excited to show them around Antalya and take them to some of the great touristy and local places here- like the old city, the fabulous swimming spots in the sea, the bus system (confusing and complex), the good shopping spots, etc. This weekend I'm reading text books, getting ready for parent groups and gym classes, maybe helping out at Curves a little, maybe going to the Turkish church service for the first time with Karn and Ishigul, and going to the market to use my newest turkish language skills! The weather is warm, but pleasant in shade with temps in the upper 80s and a little breezy. I miss you all and love you lots!

I just wrote more than 4 pages single spaced. It’s time to end this blog entry!

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