Infant Mental Health in Israel Sam Tyano, MD Miri Keren, MD Acco, Sep Acco, Sep. 2009

Israel Total population: 7.28 million Ethnic distribution: 80.1% - Jewish; 19.9%- Non Jewish: –Arabs: 14.65% (1,066,520) –Bedouins: 2.74% (200,000) –Druze: 1.64% (120,000) –Armenian: (5000)

Land surface area: 22,770 Km2 Neighboring countries: Lebanon, Syria, Jordan, Egypt

Religion 76% 16% 4.5% 1.8%

Languages spoken:Languages spoken: –Official: Hebrew, Arabic –More 17 languages Literacy rates:Literacy rates: –Total population: 95.4% –Male: 97.3% –Female: 93.6% Between 1993 and 2006, post-secondary education increased by 45% among Jewish women and doubled among Arab women. However, the educational disadvantage of Arab women remains: in 2006, 19% of Arab women, as compared with 46% of Jewish women, had post-secondary education

GNP GNP Billion $ Per capita-18,624 $

By the end of 2006, the number of Israeli children and adolescents below the age of 18 totaled 2,365,800. Of these, 69.1% were Jews; 24% Muslims; 1.9% Christians; 2% Druze; and 3% did not have a registered religion

% of total budget dedicated to health: 7.9% % of total health budget dedicated to mental health: 5.8%

Health & mental health policies and ways of enforcing them including patients' rights Under Israeli law, all citizens and de jure residents are medically insured. Medical services are delivered primarily by four public health funds (HMO-like organizations) except for mental health services, which until now have been delivered mainly by the Ministry of Health.

Ctd. Mental health care is facing a major reform effort, including a proposed shift in responsibility for the provision of mental health services from the Ministry of Health to the four public HMOs. When responsibility for mental health services shift from the ministry to public insurers, the role of the primary care physician as a “gatekeeper” and guide is likely to become even more prominent.

National Expenditure on Health, by financing sector, % 36% 27%

Specialty mental health clinics by providers, target age group and district Total N Adults only n All age groups n Children and youth-n Government & municipalities 7052 Private and NGOs Public hospitals HMOs Total

Infant Mental Health Project in Israel Stage 1 ( )- The creation of 7 units of Infant Psychiatry all around the country Stage 2 ( )- The creation of one satellite to each one of the sites

Safed kineret Dead sea Mediterranean sea Stage 1 1. Petah Tikvah 2. Haifa 3. Safed 4. Jerusalem Eitanim 5. Jerusalem Hadassa 6. Beer Shaeva 7. Ashdod

Safed kineret Dead sea Mediterranean sea Stage 2 Satellites 1.1. Rosh Haayin 2. Bnei Braq 3. Kafer Kassem 4. Nazareth 5. Tirat Hacarmel 6. Beitar Ilit 7. Eilat

Collaborative Regional projects Geha Mental Health Center was the first mental health center that initiated sharing of professional knowledge between Palestinian and Israeli Adult and Child Psychiatrists: - A two-year training course in Adult Psychiatry for professionals from Gaza Mental Health Center took place at Geha Hospital (once a month). - Geha Child and Adolescent teams went to Gaza strip, to meet local community professionals and implement workshops, frontal lectures and group supervision in Child Psychiatry. Five meetings actually took place.

CTD -The Israeli-Palestinian Infant Mental Health Training Course Project Setting: Three overnight week-ends at a hotel in East Jerusalem for a 48 (16 x 3) hours of training. Participants: 14 Palestinians from Bethlehem, Ramallah, Naplus, and East Jerusalem, with 14 Israelis from West Jerusalem. All of them are community child mental health professionals. Goal: To increase basic knowledge on core concepts of psychopathology in infancy, early detection, diagnosis, assessment and therapeutic principles, and specific diagnostic entities.

CTD -To summarize the process … Mental Health professionals from both sides of the conflict first meet in a neutral country, far from societal pressures, just to “feel” if the encounter is possible; then share knowledge. Sharing knowledge about mental processes in itself triggers affects, because of our basic identity as therapists. Mutual affective recognition leads to a change of perception of the Enemy, first in the professionals’ minds and then back in their own society through them.

Some data about the Mother Unit

1996: : New cases Petah Tikvah data

Number of sessions per month: 2004 : :

Boys Girls Gender distribution 60% 40%

Age distribution Age Number of cases 0 - 1years years years92

Sources of referral (2008) Source Nb of cases Self referred90 Well-Baby Centers58 Pediatricians56 Social welfare15 Adult psychiatrist6 Day care1 Child psychiatrist1

Who is referred to the infant mental health clinic ? Nb of cases Reasons 385 Infant (sleep, feeding, behavior, anxiety, development…) 34 Mother (depression, anxiety, difficult relationship with infant, divorce…) 11 Father (depression, anxiety, difficult relationship with infant, divorce…)

Range of change following treatment Full change % Partial change - 63% No change - 4% Range of change

Domains of change Infant’s symptoms Parent-Infant Relationship Perception of the infant 75% 14.58% %

The Unit involvement in Petah Tiqva community Consultations to Day nursery for high risk infants Training and Supervision of “Support Security” groups run by Community Nurse and Social worker. Supervision of Ethiopian community workers Consultations and Supervision in Residential nursery for waiting-for-adoption infants

The three pivots of the Project Clinic Research Teaching

Creating an academic structure aimed at training Infant Mental Health Units professionals: Authorization from the Post Graduate School of Medicine to open a 2 years program on Infant Psychiatry. The students are Multidisciplinary Senior professionals. Structure of the 6 hours a week course: –lectures on clinical infant psychiatry –pediatrics, general, legal, ethical, economical and other community issues –Small groups clinical discussion of videotaped normal infants (first year of the course) and supervision on cases presented by the students (second year of the course).

One more step: A computerized chart for all the Units The aim: To develop a common clinical, research and epidemiological conceptualization of our work.

Integrating research into clinical routine work at the Unit It is crucial for - Continuously showing the need and the impact of work with infants. - Increasing the team’s level of knowledge. - Understanding better the field we are in… - Defining our own identity by combining our theoretical definition with what we actually do. Two types of research: - Descriptive and comparative. - Longitudinal (videotaped) follow-ups.

Projects for the near future To consolidate the existing satellites and expand them in accordance with local needs. To create centers for intensive care where parents and infants can come three to four times a week and get a therapeutic accompaniment,a parental education and support. To establish a national-based preventive program, based on professionals’ home visits, aimed at reducing the percentage of infants at risk for later psychopathology, and improving parents’ coping with challenging infants. To enlarge the collaboration with Palestinian IMH professionals

Vision for future Planning actions for fighting the stigma around Infant Psychiatry. ( See WPA awareness Project on Child Psychiatry 2007 ) Improving the collaboration between Social welfare, Ministry of Health, Pediatricians, Psychologists and Child Psychiatrists working with Infants.