The Dance of Service

By Monica Morela, behavioral aide at Connecting Dots

Many scholars within the field of disability studies illustrate the relationship between service providers and families by using different analogies. Yuen (2003) describes how having a child with a disability can be like embarking on a journey to space. Such a quest can be exciting at times, lonely, or scary; and asking for help along the way is always necessary. Alternatively, parents describe having a child with a disability as feeling like a spider sitting on a web (Yuen, 2003). Where weak strands are strengthened by connection, and where a ‘web’ of professionals are there to help. I think that Fialka (2001) beautifully illustrates the professional-family relationship by comparing this connection to a dance. In service provider relationships and in a dance, there is an element of forced intimacy. The nature of our circumstances brings us nose-to-nose with strangers in ways that can be awkward. Being aware of this awkwardness can help behavioral aides and therapists to think about how we can reduce the number of times we step on toes!

Another dimension of Fialka’s (2001) illustration that I found very poignant was the idea of who leads the dance of services. Many practitioners will refer to parents as the experts on their children. It might be more accurate to refer to parents as contributors. In a dance, each individual’s contribution can evolve and build on each other as we offer different perspectives about a child. Finally, in a dance, each partner listens to music that guides the movements of their dance. In the dance of services, ‘music’ can be an illustration of priorities. Priorities for parents and service providers can sometimes differ. This difference can lead to misunderstandings regarding the role and goal of services. When practitioners are willing to put on parents ‘headphones’ they will hear the experiences of parents and will be more effective in strengthening the parent-professional relationship.



Fialka, J. (2001). The dance of partnership. Young Exceptional Children4(2), 21–27.

Yuan, S. (2003). Seeing with new eyes: Metaphors of family experience. Mental Retardation, 41(3), 207-211. doi:10.1352/0047-6765(2003);2

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The Importance of Small Talk

By Monica Morela, behavioral aide with Connecting Dots

Lynne-McHale and Deatrick (2000) describe trust as being, “the cornerstone of helping relationships” (p. 211). This statement is also corroborated in Reeder and Morris’s (2018) qualitative study regarding the importance of trust in therapeutic relationships. They found that in some cases a positive therapeutic relationship was more strongly correlated with positive treatment outcomes than the choice of what treatments to use (Reeder & Morris, 2018). Reeder and Morris (2018) also found that although professionals are aware of the importance of trusting relationships, they were not always clear on how to achieve a positive trusting relationship with families. So how do we as practitioners and behavioural aides authentically gain the trust of the families we work with? The answer might be more attainable than we think! Francis et al. (2016) examined parent perceptions of best practices for building trust in professional relationships. They found that one of the most important skills for building trusting family-professional partnerships was communication (Francis et al., 2016). More specifically, engaging frequently with clients in casual and positive conversations has been described by parents as one of the best ways to build trust (Francis et al., 2016). This means that our beginning of session chats about the weather and our weekends might be more important than we think! Edwards et al. (2018) provide more detail regarding key communication skills that can help us as service providers build positive working relationships. Taking the time to listen, using proper eye contact, remaining attentive, and being clear are all communication skills that can aid us in building a positive therapeutic relationship.

I think that we can treat building rapport and trust as a skill. Taking an intentional, conscious, and conscientious approach to providing care will be beneficial for us as practitioners but also for the families we work with. The next time you are working with your clients maybe take some time before the session to chat with parents about their day. Taking this time to build a positive relationship might go farther than you think!



Edwards, M., Parmenter, T., O’Brien, P., & Brown, R. (2018). FAMILY QUALITY OF LIFE AND THE BUILDING OF SOCIAL CONNECTIONS: PRACTICAL SUGGESTIONS FOR PRACTICE AND POLICY. International Journal of Child, Youth and Family Studies9(4), 88–106.

Francis, G. L., Blue-Banning, M., Haines, S. J., Turnbull, A. P., & Gross, J. M. (2016). Building “Our School”: Parental Perspectives for Building Trusting Family–Professional Partnerships. Preventing School Failure: Alternative Education for Children and Youth60(4), 329–336.

Lynn-McHale, D. J., & Deatrick, J. A. (2000). Trust Between Family and Health Care Provider. Journal of Family Nursing6(3), 210–230.

Reeder, J., & Morris, J. (2018). The importance of the therapeutic relationship when providing information to parents of children with long-term disabilities: The views and experiences of UK paediatric therapists. Journal of Child Health Care22(3), 371–381.

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Working with Diverse Families

By: Simran Saroya

Hi everyone!

I wanted to shine some light on a topic I am very passionate about and that is culturally diverse families and what opportunities look like for them. As we work with diverse families and diverse circumstances, we must acknowledge the culture in the homes vs. the culture we may be accustomed to. Western culture is what we base most of our observations and inferences on. What we must understand is that nonverbal and verbal communication looks different across all cultures. For example, eye contact may be an indicator to us that a child is paying attention although in other cultures it may be a sign of respect that they are not meeting eye to eye. It is very important for families, aides and therapists to talk about cultural norms and what that may look like in their household. Another example may be head-nodding for “yes” or “no” answers. In a western worldview, horizontal head-nodding means no, and vertical head-nodding means yes. In other cultures such as Bulgarian, this is completely the opposite. Although most children are accustomed to the western system, it is important to recognize that some may not be and this conversation is important. Lastly, I wanted to share an example of sharing feelings across cultures. As therapists and aides we encourage children to share feelings and express emotions openly while some cultures such as eastern cultures may not encourage speaking about feelings openly.

The biggest takeaway from this short blog post is that cultural norms are very important to understand especially when working with children from many different family backgrounds and dynamics. We definitely understand that all systems in a child’s life are connected and can impact them, but culture is one system that has a huge impact. By better understanding the roles in the home, the child’s needs, the child’s expectations in the house and the parents expectations, we are able to help the children much better.


I found some resources that can help us understand different cultures a bit better when working with children and their nonverbal vs. verbal responses. I will link them down below.

This one talks about eye contact and the differences across all cultures :

This one talks about head nodding and the differences across cultures around the world :

This one talks about emotions:

Prezi on Emotions:

Nonverbal communication examples:

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Overcoming fear by providing a therapeutic environment

By: Asmaa Fellah

Starting school (including preschool and kindergarten) is a major transitional event in children’s lives. With transition comes change, and with change comes coping and adapting. For many children, coping with change can be very daunting and intimidating, especially when children have fears. Children are scared of being away from their parents in a new setting and environment. In addition, they are also scared of rejection, meeting new people, and failure. 

In kindergarten, many children begin to feel separation anxiety and will start crying, yelling, screaming, and throwing temper tantrums, especially on the few first days. Children are attached to their parents, and therefore feel a sense of securement when their guardians are in their environment. Rather, when children are away from their guardians for the first time and for long periods of time, he or she feels lonely and scared. Not only do they feel scared, but their environment also is completely new to them and they feel lost and overwhelmed. Their sense of securement is instantly gone, leaving them with a sense of fear from their new environment. This is a commonly seen fear amongst kindergarteners. 

As children continue in their schooling, expectations and accomplishments are expected from teachers and parents. Homework and assignments are expected to be completed, inside school grounds and outside school grounds. Fear of failure starts to arise as children may be overwhelmed with how much they need to get done, or maybe the difficulty of the tasks, or the pressure of parents and teachers. Fear of failure may prevent them from enjoying school as it will feel forced and unwanted. In addition, children may think that if they don’t meet these expectations and complete their work, a harsh consequence may be set. 

The mentioned fears and concepts are applicable to how protentional feelings a child might feel prior to and during an in-home service. Remember, you are a complete stranger to this child and in their point of view, you might be invading their territory. In addition, that child doesn’t have other children around him or her, so they might feel more singled out leading to increased feelings of fear. Now how do we overcome this?

Time and patience. One must understand the difficulty that a child endures when trying to become comfortable and opening up to strangers. In a situation where an in-home aide only has 4 hours, this becomes exceptionally more difficult as it takes longer for the child to become comfortable and adapt.

Second, it is crucial to provide a therapeutic environment that includes the least restrictive environment is necessary for children’s growth and development. A least restrictive environment (LRE) is incorporated in a therapeutic environment. The more negative and unsafe environment, the more children are least likely to learn appropriate behavior to adapt to new environments and events. Proper educational and behavioral support includes an LRE that incorporates a therapeutic and engaging environment, allowing students to prosper and flourish intellectually, emotionally, and socially. 

When a student feels safe, he or she is more likely to engage in actions and adventure outside of their confront zone. On the other hand, a student is more likely to present inappropriate actions such as not listening, and engage in inappropriate behavior if the safety component is not presented in their environment. Students use these tactics as a defense mechanism in order to create a sense of safety. A safe environment also creates a sense of welcome and is composed of mutual respect, no-judgment rule. When teachers engage in welcoming actions such as smiling at their students and asking how they’re doing, the students are less likely to be guarded and rather open up and show their true selves. Providing a no-judgment rule allows for students to feel safe to take new opportunities, experiment with new strategies, and engage in new appropriate behavior. 

An LRE environment speaks about the accessibility to preferred activities for exceptional students which in turn increases responsiveness to new behavior. Much the same as adults, youngsters have interest and preference which makes them more inclined to complete a task when these are available. Students are also more likely to rebel against the teacher which results in inappropriate behavior if the task is too boring or too demanding. It is important to relate academic and non-academic tasks to the preferences of the exceptional student when possible. When tasks personally relate to the student, he or she is more like to be engaged in the activity. The accessibility to preferred activities also fosters creativity and active learning for these students. Realistically, not all tasks are relatable to different interests nor appeal to students, rather rewarding them after a completed task with an interest of theirs is also effective. For example, a reward for a student who enjoys reading could be ten extra minutes of preferred reading after finishing a math worksheet. Using these techniques increases the chances of responsiveness and participation for all students and can in turn lead to increased active learning. 

To summarize, utilizing these strategies allows aides to create a sense of security and welcoming. We all must be patient in regards to children opening up. It is crucial to allow enough time, create a positive atmosphere and allow the child to engage in activities they love. These strategies not only benefit’ the aides but also allows students to take risks and new attempts without feeling embarrassed or afraid.


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The Effects of Exercise on Major Depressive Disorder

By: Maryam Abro


Major depressive disorder (MDD) generally known as clinical depression is very common and seriously challenging for the health care system due to its recurrent and treatment-resistant characteristics (Morres et al., 2019) and one of the leading causes of years lived with disability (YLD) (James et al., 2018 as cited in Pitsillou et al., 2020). MDD is a common disease and affects people of different ages and social backgrounds (Moussavi et al., 2007). It is estimated that depression affects 322 million people worldwide and the number of people living with depression increased by 18.4% between the years 2005 and 2015 (WHO, 2017).

MDD is no longer considered as a discrete disease with simple cause and symptom and believed to be “multidimensional” (Clark et al., 2017 as cited in Pitsillou et al., 2020). MDD is characterized by an assortment of “physiological”, “psychological” and “cognitive symptoms” and it is diagnosed based on a collection of specific symptoms as there are no objective diagnostic tests (Cullen, Klimes-Dougan, Kumara, & Schulz, 2009). The clinical description of depression is mood disturbance for example sad, low, or irritable mood or a persistent loss of interest or pleasure, and must be manifested with additional biological, cognitive, and emotional symptoms such as sleep disturbance, poor concentration, and feeling of worthlessness (Curry, & Hersh, 2014). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), MDD is categorized by peculiar changes in “affective”, “cognitive” and “neurovegetative” domain with symptoms lasting for at least 2 weeks. Moreover, five or more symptoms need to exist in the same event and at the minimum one of the signs as depressed mood or “anhedonia” and other symptoms being unexplained substantial weight change, fatigue or weakness, feelings of guilt or insignificance, difficulty concentrating and frequent suicidal thoughts (AMA, 2013 as cited in Pitsillou et al., 2020). Individuals with MDD become socially isolated and report decreased enjoyment in social connections (Bora & Berk, 2016) and are at greater risk of suicide. Suicide is the third leading cause of death in 10 to 24 years old and 50% of the time the cause is related to MDD (Cullen et al., 2009).

MDD is more common in adolescents than in younger children (Curry, & Hersh, 2014) and the prevalence in women is double as compared to men. MDD follows a recurrent course and on average individuals experience five to nine Major Depressive Episodes (MDEs) and with each recurrence, the time between episodes becomes shorter and shorter (Pizzagali, Whitton, & Webb, 2018). Depression damages health to a greater extent than any other disease (Moussavi et al., 2007) and is “highly comorbid with other mental disorders, most prominently anxiety disorders (59%), impulse control disorders (32%), and substance use disorders (24%), and collectively almost 75% of adults with lifetime MDD report at least one other lifetime DSM disorder” (NCS Replication; Kessler et al., 2011 as cited in Pizzagali et al., 2018). Several studies have suggested that MDD is connected with neurocognitive damage mainly in attention and “executive function” and severity of depressive symptoms are directly related with cognitive difficulties (Bora et al.,2013; Lee et al.,2012; Snyder, 2013; Trivedi and Greer, 2014; Wagner et al.,2012; McDermott and Ebmeier, 2009 as cited in Bora & Berk, 2016). Furthermore, MDD is also linked with other illnesses such as cardiovascular disease, diabetes, arthritis, asthma, and chronic pain (Baxter, Charlson, Somerville, & Whiteford, 2011 as cited in Pizzagali et al., 2018). Due to comorbidity with other mental and physical illnesses, the individuals suffering from MDD have a greater risk of premature mortality and generally have approximately 10–15 years shorter life expectancy (Gerber, Holsboer-Trachsler, Pühse, & Brand, 2016).

The traditional treatment for MDD is pharmacotherapy, psychotherapy or a combination of both (Gerber et al., 2016). In severe cases of depression, electroconvulsive therapy (ECT) can also be used (Pandarakalam, 2018 as cited in Pitsillou et al., 2020). Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), norepinephrine-dopamine reuptake inhibitors (NDRIs), tricyclic antidepressants (TCAs), or monoamine oxidase inhibitors (MAOIs) are some of the standard medication used for treatment of MDD (Gelenberg et al., 2010).  These drugs act on the monoamine system and increase the availability of serotonin (5-HT), norepinephrine and dopamine in the brain (Pitsillou et al., 2020).

The “heterogeneity” of depression poses serious challenges for traditional treatments (Kandola, Ashdown-Franks, Hendrikse, Sabiston, & Stubbs, 2019). The treatment outcome for pharmacotherapy and psychotherapy are not broad and 34% of people with depression tend to be non-responsive to treatment (Cipriani et al., 2018; Cuijpers et al., 2019; Rush et al., 2006 as cited in Kandola et al., 2019). Currently, antidepressants are prescribed on a ‘trial and error’ approach (Serretti, 2018 as cited in Pitsillou et al., 2020) and it is estimated that only 30% to 50% of patients respond to “single-action” or “dual-action” monotherapy and majority of patients require change or increase in medication (Gerber et al., 2016). Furthermore, antidepressants can cause various side effects (Anderson et al., 2012 as cited in Kandola et al., 2019).

The traditional treatments for depression such as pharmacotherapy and psychotherapy will continue a pivotal role in the treatment, however, considerable number of people with depression do not pursue treatment and more than 50% of patients, who even seek treatment do not respond effectively and require additional treatment options, which most of time do not provide remission. Consequently, new and complementary treatment options are urgently need (Gerber et al., 2016; Kandola et al., 2019). Physical activity has proved to be effective alternative option for the treatment of depression (Karg, Dorscht, Kornhuber, & Luttenberger, 2020).

Effects of Exercise

Notwithstanding widespread research on the effectiveness of exercise, the exact mechanisms through which antidepressant effects are produced have not been established. It is believed that exercise produces antidepressant effects through numerous biological and psychosocial avenues (Kandola et al., 2019).

Biological Mechanisms

The neurobiological mechanism theory suggests that physical activity increases cognition and mental health by changes in the structural and functional composition of the brain (Lin, & Kuo, 2013; Dishman, & O’Connor, 2009 as cited in Lubans et al., 2016). Voss et al (2013) described three main categories that are impacted by exercise:

  1. Cells, molecules and circuits;
  2. Biomarkers- gray matter volume, cerebral blood volume, flow;
  3. Peripheral biomarkers- circulating growth factors, inflammatory markers (as cited in Lubans et al., 2016).

Several meta-analyses have discovered the relation between depression and structural abnormalities in the brain such as a decrease in hippocampal, prefrontal, orbitofrontal, and anterior cingulate cortex volumes (Bora et al., 2012; Du et al., 2012; Kempton et al., 2011; Koolschijn et al., 2009; Lai, 2013; Sacher et al., 2012; Schmaal et al., 2015; Zhao et al., 2014 as cited in Kandola et al., 2019). In people with depression, the hippocampus is the commonly affected area in the brain (Schmaal et al., 2015 as cited in Kandola et al., 2019). The hippocampus is associated with emotional processing and stress regulation and these regions are mainly affected by depression (Zheng et al., 2019; Dranovsky and Hen, 2006 as cited in Kandola et al., 2019).  Animal models suggest that depression impairs various cellular processes, including hippocampal neurogenesis (Anacker et al., 2013; Eisch and Petrik, 2012; Hill et al., 2015; Sahay and Hen, 2007 as cited in Kandola et al., 2019) and it is believed that decreased rates of hippocampal neurogenesis are partly accountable for depressed mood (Duman, Heninger, & Nestler, 1997 as cited in Rethorst et al., 2009).

It is believed that antidepressant effects of exercise are related to physiological changes that triggers hippocampal neurogenesis (Ernst et al., 2006 as cited in Rethorst et al., 2009). In animal studies, it has been observed that exercise results in changes in brain-derived neurotropic factor (BDNF), increase in cell proliferation, survival, and differentiation. Further, it stimulates the growth of new capillaries that are vital for the transportation of essential nutrients to neurons and results in an increase in neurochemicals, e.g. brain-derived neurotrophic factor (BDNF), insulin-like growth factor 1 (IGF-1), and vascular endothelial growth factor (VEGF) ( Van Praag, 2008; Kleim, & Cooper, 2002; Cotman, Berchtold, & Christie, 2007 as cited in Lubans et al., 2016).


Several meta-analyses, Dowlati et al. (2010); Howren et al. (2009); Köhler et al. (2017); Valkanova et al. (2013), suggested that people with depression have raised levels of pro-inflammatory markers, including Interleukin (IL)-6, IL-1, Tumour necrosis factor-alpha (TNF-α), C-reactive proteins (CRP) and several other IL receptors and receptor antagonists (as cited in Kandola et al., 2019).  Inflammation can interrupt several pathways involved in depression e.g., “dysregulating BDNF” or “neurotransmitter systems” via “kynurenine pathways” (Kiecolt-Glaser et al., 2015; Calabrese et al., 2014; Cervenka et al., 2017; Schwarcz et al., 2012 as cited in Kandola et al., 2019).

Studies have noted reduction in number of “circulating inflammatory factors” such as IL-6, IL-18, CRP, leptin, fibrinogen and angiotensin II due to exercise (Fedewa et al., 2017, 2018; Lin et al., 2015 as cited in Kandola et al., 2019). In a recent Randomized control trials (RCT) on 98 participants with MDD by Euteneuer et al. (2017), an increase in anti-inflammatory marker IL-10 in the plasma was observed in experimental group- undergoing CBT with exercise as add on (as cited in Kandola et al., 2019). Similarly, in another 12-week study, reduction in depression symptoms and serum samples of pro-inflammatory IL-6 was noticed due to exercise (Lavebratt et al., 2017 as cited in Kandola et al., 2019).

Psychosocial and Behavioral Mechanism

People with depression have lower levels of self-esteem that could be potential reason for sense of worthlessness (Keane and Loades, 2017; Orth et al., 2008; Van de Vliet et al., 2002 as cited in Kandola et al., 2019). A negative association exists between weight status and mental health. People who have dissatisfaction with body image have higher risk of depression and show significantly lower scores on physical self-perceptions (Ali et al., 2010; Tang et al., 2010; Jackson et al., 2014; Van deVliet et al., 2002 as cited in Kandola et al., 2019).

Cross-sectional studies suggest that physical activity is linked with higher self-esteem scores, QOL and positive affect due to physical self-perception (Feuerhahn et al., 2014; Sani et al., 2016 as cited in Kandola et al., 2019). Legrand (2014) found that 7-week exercise intervention resulted in increases in physical self-perception, self-esteem, and decreases in depressive symptoms in women with elevated depressive symptoms (as cited in Kandola et al., 2019). Further, physical activity assist contact with the natural environment and could improve mood that affect wider affective states and other signs of well-being (Deci, & Ryan, 2002; Ryff, & Keyes, 1995 as cited in Lubans et al., 2016). Ossip-Klein et al (1989), in a study of clinically depressed women, found that exercise, both aerobic and resistance training, resulted in increased self-esteem and a decrease in depressive symptoms. The authors suggested that an increase in self-esteem may be responsible for decrease in depressive symptoms and contributed to higher self-esteem to improved body image and increased mastery (as cited in Rethorst et al., 2009).

The behavioral mechanism theory contends that changes in mental health outcomes due to physical activity are facilitated by changes in applicable and related behaviors, for example, involvement in exercise may result in better sleep length, sleep effectiveness, sleep latency and reduce sleepiness. Furthermore, partaking in physical activity may also affect self-regulation and coping skills that have potential implications for mental health (Stone, Stevens, & Faulkner, 2013; McNeil et al., 2015; Lang et al., 2013; Gaina et al., 2007 as cited in Lubans et al., 2016). Meta-analytical studies have displayed that exercise increases total sleep, increases slow-wave sleep, and decreases REM sleep resulting in a substantial decrease in Serotonin discharge during REM sleep (Kubitz et al., 1996; Youngstedt, O’ Connor, & Dishman, 1997; McGinty, & Harper, 1976 as cited in Rethorst et al., 2009).

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