Starting out as an occupational therapist specialising in sports medicine and musculoskeletal disorders, Miguel Valles has grown to be one of the leading figures in family-centred Early Childhood Intervention (ECI) in Portugal. After gaining experience in working with children in special education schools, he developed a project to support children in mainstream public schools, especially in terms of processes of inclusion.

He has now worked within CECD Mira Sintra for 24 years, eventually becoming the President of the Board and Secretary General of the organisation. They are now 220 employees strong with different social businesses and activities, focusing on persons with intellectual disabilities.

In this interview, we get a closer look at his own ECI story, his approach to this model of intervention, and how he responds to the challenges and external pressures pushing back against the family-centred model.

Let’s start from the beginning – tell me your story. What was your journey to working in the ECI sector?

Being an occupational therapist in physical rehabilitation is what lead me to CECD Mira Sintra. However, my first experiences with ECI were difficult ones.

I came from a university hospital, where my studies were focused on [physical] health. The training emphasised that the therapist’s decision was the only one that mattered – we were the experts. You would be taught to evaluate the child, and then prescribe treatment; there was no consideration for the family, their environment, or their resources. This was unfortunately the mindset I had in my first few years of work. This was back in the nineties, and academia has unfortunately not changed much since then.

I first started to doubt this way of interacting with families when I prescribed a specific treatment (rigid leg braces) for a young child. This was a painful treatment that would take up two hours per day at home. The provision of this service was given only in the hospital, so I had no knowledge of the child’s environment, or their family life – I had never visited their home.

I soon found out that the family wasn’t following the treatment [I prescribed] and, as a result, my initial reaction was to stop working with them and the child. Luckily, I had the opportunity to speak with the parents, and the father was very honest. He told me that whilst he knows the treatment is best for his child, he only has 30 minutes to spend time with them after working the whole day. He didn’t want to cause her pain during the only interaction they had together. It’s unreasonable. He then said he would have mentioned this earlier but knew that his opinion isn’t valued by the medical sector. This was my first real encounter with ECI.

From that point on, I began to unlearn and reframe all aspects of my interactions with families I worked with. I began to see the whole family as the client. Instead of prescribing one treatment, I shared my knowledge with the families, presented several possible solutions, and then supported the family with the treatment they decide to go for. Shortly after, I formed a team which now supports over 200 children and our approach is very straightforward: we share knowledge with the family. We start by asking the family, “How can we help you?”, instead of jumping straight into a diagnosis.

As medical professionals, we must learn to accept that the family is the expert on the child – not us. We must see them as partners in ECI.

I look back and see how horrible my first reports were – they followed such a medical approach and I wish I could throw them out!

In your own words, how would you define ECI?

For me, ECI is a service focused on the child and their family. It’s one that supports families by giving them the tools and knowledge to better protect their child who either has a disability or is at risk of developmental delays.

I also think that ECI is defined by relationships based on trust – I must trust the family and follow their expertise [on the child]. It’s not my position to critique or impose my values onto them. At the very beginning, it’s important to only address the issues the family brings up. It is only after you gain their trust that you can start focusing on suggesting therapies that you believe are more likely to ensure a better future for the child.

From your day-to-day work, could you describe the effects of the paradigm shift towards a family-centred model?

Well, I realised that the past model of intervention was very hard and quite strenuous for therapists. Many hours were dedicated to the treatment alone (around four 1-hour sessions per week), and the results were not great in the end.

By working with parents, I could extend my knowledge and practice to another parent or professional who could work with that child during the whole day. In this way, a family-centred model is more holistic, which is important because we aren’t just treating a leg or a foot – we are working with a child. You are helping them to enter school, to cope with life challenges, and with their emotional development. For professionals, it’s easier to only focus on the “the leg”, but separating the physical from the mental and emotional needs of the child is detrimental to their wellbeing.

You’ve been part of the creation of an ECI system in Portugal, which is considered one of the best-developed systems in Europe. What do you think other countries and organisations that want to create ECI systems in their own contexts should keep in mind?

One of the most crucial aspects of the Portuguese model is that it’s transdisciplinary. This means that all the different departments that intersect when it comes to the needs of the child – such as health, education, and leisure – should exchange knowledge and work together.

This collaborative approach is a bit harder to achieve because the different departments often criticise one another, and it essentially becomes a blame game! On top of this, none of them evaluate their own performance – they all work in an isolated way.

The rigid “separation” of departments often leads to parents giving information in a disconnected way to each team. As a result, no one has the full picture, and none of the professionals can see the full extent of the family’s resources and what kind of therapy they are using. From the parents’ perspective, they see that the more support, more professionals involved, and more hours of therapy for their child, the better, which isn’t necessarily the case because there’s no coordination.

It’s also important to keep in mind that the transdisciplinary framework is harder for professionals because they lose some of their “power” and status as experts. There’s a lot for them to unlearn and reframe in a professional sense.

At the end of the day, exchanging knowledge helps us focus on what’s important: the needs of the child. What’s the next stepping stone for them? When the child becomes 6 years old, they’ll enter the education system - what can we do to prevent their exclusion? All departments and professionals should follow a common path to address the main priorities and concerns of the family by working together.

How do you resist barriers or external pressures that push against ECI?

On a national level, we have champions of the family-centred model working in the ministries within the government. Additionally, it’s vital to invest in models that are cost effective.

When it comes to encouraging this model on a more local level, it’s important to invest well from the very beginning. Months of investment can have a really big impact on the child’s future. Early investment can result in parents knowing what they must do, and choosing the best therapies for their child. My role here is to be completely honest. For example, providing families with multiple scenarios and what their potential outcomes are, defining a plan with the family, and encouraging them to defend the needs of their child at school or medical appointments.

This system can also challenge your own views, which means you must accept that you have to unlearn and reframe how you approach ECI.

To end on a positive note, what makes you most proud of the work you do?

I’m very proud when I present the work of Portugal. It’s great to see our work being embodied at a national level. It’s a lucky coincidence that our model would be adapted into law. However, maybe the proudest thing is that we continue our work and resist pressure from the outside, such as professionals who want this new system to fail, so they can continue charging an hour of service to families.

About Humans of EASPD

Humans of EASPD is a social media campaign that we have launched for 2023 leading up to our upcoming summer conference in Tirana.

Over the span of five weeks, our campaign will dedicate a post to one of our humans to spotlight the work of our members in the field of Early Childhood Intervention.

Each post will present a unique story of an individual, sharing their journey within the field and shining a light on the personal significance ECI can have in someone’s life.