The concept of "Snoezelen"or controlled multi-sensory stimulation was introduced by staff working at two Dutch centers for persons with intellectual disability (ID) in the 1970s (Hulsegge & Verheul, 1987; Shapiro & Bacher, 2002)). The word "Snoezelen" is a combination of two Dutch words: snuffelen or the sniffing of a dog and doezelen meaning to slumber, relax or doze (Hulsegge & Verheul, 1987; Shapiro & Bacher, 2002). Snoezelen refers to a specially equipped room(s) where the nature, quantity, arrangement and intensity of stimulation is controlled (Shapiro & Bacher, 2002) with an environment designed to stimulate the senses by means of light, sound, touch, smell and taste (Lindsay et al. 1997).

The founders of the concept (Hulsegge & Verheul, 1987) used the method as a leisure or relaxation activity without therapeutic elements or supervision and initially resisted any notion of research in the fear that it would become more therapeutic, objective and product oriented (Lancioni et al. 2002). Over time though this has changed and a recent review (Lancioni et al. 2002) identified 21 research studies, where 14 studies involved persons with ID and seven studies people with dementia. Of these studies 14 reported positive effects within the session in the Snoezelen room, four showed positive post-session effects and two long-term effects.

Snoezelen was first introduced in Israel within a day-treatment center for children with ID in 1993 (Shapira et al. 1997; Shapiro & Bacher, 2002) and the first Snoezelen room within the Division for Mental Retardation (DMR) was established at one of the residential care centers in 1995. This method is today used in Israel in more than 25 residential care centers and three community settings for persons with ID. From the year 2000 a part time physiotherapist has been employed to supervise the treatment and the development of the method nationally for the DMR. Professional meetings among the staff are taken place every four months and a certification course has been established on a national basis for the different professionals involved (occupational therapists, physiotherapists, teachers, musical therapists, nurses, speech therapists or care givers). The first handbook (Shapiro & Bacher, 2002) for practitioners was published in 2002.

Also in the year 2000 the Ministry of Education has introduced Snoezelen as a treatment concept for students enrolled in special education programs around the country and recently several nursing homes for the elderly and also rehabilitation institutions for the disabled have taken up the method. The major medical center for children in Israel, Schneider Children's Medical Center, has also established Snoezelen in their surgical department.

The concept of Snoezelen was introduced in residential care centers for persons with intellectual disability (ID) in Israel in order to add to the variety of treatment possibilities for this population. It was seen as another instrument for communication between therapist/caretaker and client. The concept also made it possible for multidisciplinary interaction between caretakers and professionals.

In one residential care center for children with ID the occupational therapist started work with the social worker within the Snoezelen room, which opened new horizons for the treatment of the entire family. The purpose of this presentation is to present one novel concept of working with the whole family.

{mospagebreak}Methods

In contrast to Holland where the primary use of the Snoezelen has been relaxation and leisure time (Hulsegge & Verheul, 1987), the focus in Israel has been on treatment from the start and therefore assessment of the client before, during and after treatment in the Snoezelen room. The client has the choice of which environment in the room he wants, but the therapist is there to activate the client, so that the time spent in the room is active time. The time in the Snoezelen room is usually limited to 30 minutes and most treatments today are performed on a one-to-one basis. The Lev Hakadosh, Residential Care Center for Children in Haifa decided on a family approach.

Study design and goals

The Snoezelen room at Lev Hakadosh started operation in July 1999 and each resident was evaluated as to his/her function and reaction to the different stimuli in the room. In October 2000 it was decided to involve the parents in the experience and invite them to participate in the sessions. This worked fine until the day one whole family arrived (parents and three siblings) and all wanted to participate in the session. The staff adapted quickly and it turned out to be a most spectacular session and on the basis of that experience we decided on a social work project to work with the family.

The goals were to facilitate a family encounter with the child with intellectual disability (ID), to enable parents and siblings to become better acquainted with the resident through his/her strength and special abilities, to provide family leisure activity, to encourage parental involvement in the care, to encourage more visits, to improve quality of life (QoL) for the resident and to reinforce a better relationship between resident, family and home.

Another goal of this study was to review the literature on social work interaction through the Snoezelen method.

Participants

Lev Hakadosh or Sacre Coeur, Residential Care Center for Children in the city center of Haifa operates under the authority of the Catholic Church is funded and under supervision of the Division for Mental Retardation of the Ministry of Labour and Social Affairs. Within the center there are a total of 61 residents with 31 residents (17 boys, 14 girls) aged 0-9 years, 28 residents (15 boys, 13 girls) aged 10-19 years and two residents (one male, one female) aged 20-22 years. All residents are patients with either severe or profound levels of ID, who require nursing treatment. Eight have nasogastric tube, 15 percutaneous endoscopic gastrostomy (PEG), two have Down syndrome, 42 suffer from epilepsy, four are blind and all are wheel chair bound. In the family social work project all families were invited to participate.

The staff involved consisted of the occupational therapist and social worker.

Procedures

minutes) was free activity with a happy, active and play atmosphere with visual effects and music. The second part was more structured (duration 15-30 minutes) with a relaxed, quiet atmosphere with appropriate light and music. In the first part the children played, laughed and enjoyed themselves together with their sibling with ID and the role of the occupational therapist was to guide the activities, while the social worker participated, answered questions from the parents or addressed emotional issues that came about. In the second part the family lied down, relaxed and massaged the child with ID with oils and often the siblings also requested massage. In the first part the music was more energetic, while more slow and magical in the second part. 

{mospagebreak}The family project

From December 2000-June 2002 (18 months) we had a total of 210 family sessions (average of 11.7 session per month) with a total of 47 families, who participated (77% of the 61 families). 31 families had 1-5 sessions, 12 families participated in 6-9 sessions and four families 10 or more (range 1-21 visits). In contrast, for the proceeding 12 months before the project started, parents visited on an average of four visits per month.

Much of the resulting data from the project was gathered through conversations with the parents, with the siblings and discussions among the professionals, since this project worked without a formal research protocol.

The parents expressed satisfaction with the sessions, they enjoyed seeing their child smiling, active and happy with the opportunity to interact with the child and also the siblings in a relaxed and somewhat magical atmosphere. The parents also reported that the siblings talked about the room at home, they more often asked to visit and were very excited on the days when they knew they would visit our center. The siblings were always very excited and disappointed when the sessions ended. They said the room was fun and asked when they could come again. The child with disability could experience more intimacy with the parents and siblings, more body contact and manipulation.

Between the professionals we realized that the room facilitated a more relaxed interaction with the parents, who often revealed intimate emotional discussions about the earlier experiences, their fear, grief and sadness about having a child with disability, which opened up new opportunities for therapeutic conversations and support.

Several case examples can illustrate the positive effects of the Snoezelen room in this setting:

• One mother had experienced problems with touching her disabled daughter since birth, but with support and help she now realized that it was possible to receive and give closeness and warmth to her child in this relaxed atmosphere.

   

• Another family had visited their child infrequently and not at all for more than six months. When they were invited and came they experienced a very close contact with their child, who then died a few days later due to serious health problems. The family expressed gratitude for having had the opportunity to part with their child this way and will always remember this last visit with a positive feeling.

   

• One family had never dared to have their child home for visits in the three years he was in the residential care center due to fear from the difficulties at home prior to placement. After a few months of sessions, where we worked with them on this issue they took him home for three days and described a relaxed and happy visit at home with the siblings and extended family. This enabled the family to now have the child at home on a regular basis.

   

• A single mother arrived for weekly sessions and experienced her child alert, responsive and warm in the room with her. These sessions gave her an important memory of her relationship with her child, when the child died six months later.

   

{mospagebreak}The computer search (March 2003)

The search of Medline/PubMed identified a total of 23 studies. Nine studies involving Snoezelen and older persons or persons with dementia, seven concerned with chronic pain management, four with persons with ID, one a general paper, one of behavior effects and one on a pediatric intensive care unit. Social or family work approach was not found.

The Social Science Information Gateway (SOSIG) had no information on Snoezelen, while Scirus had 31 journal results and 363 web results, but none on social or family work.

APA on-line, PsychCrawler and World Wide Web Resources for Social Workers had no results on Snoezelen at all, while Ingenta found seven papers and Infotrieve 53 papers, but none on social or family work.

Discussion

In recent years there have been a few reviews on research studies and Snoezelen. Schofield & Davis (1998) from Sheffield, United Kingdom reviewed the literature from the nursing perspective concerning sensory deprivation research. The issue of sensory deprivation dates back to the 1950s, but in fact already highlighted by the nursing pioneer Florence Nightingale (1820-1910) a century before (Schofield & Davis 1998). This review combined sensory deprivation, or rather sensory restriction, with chronic pain and suggested Snoezelen as a treatment tool (Schofield & Davis 1998), which resulted in a study of 73 patients with chronic pain (Schofield & Davis 2000). Their study compared Snoezelen with a traditional relaxation program and found that patients, who experienced the Snoezelen environment did slightly better that the control group in terms of pain and self-efficacy (Schofield & Davis 2000).

A recent Cochrane review (Chung et al. 2002) was performed of two studies with older persons with dementia. The two studies reviewed (Kragt et al. 1997; Baker et al. 2001) examined the short term effect of Snoezelen, but the Cochrane review could not conclude anything about the effects due to limited data, different methodology and control conditions. The authors of the review therefore appeal for further systematic and scientific studies in order to examine the clinical value of Snoezelen for persons with dementia.

Studies on Snoezelen and persons with intellectual disability were recently reviewed (Lancioni et al. 2002) and 14 studies had taken place within this population. Studies have been both with children and adults with moderate to severe and profound intellectual disability and the scientific evidence of positive effects of this treatment should be taken with some caution. The option of Snoezelen in a population with few or limited treatment solutions has made this a popular approach. The majority of the studies reviewed (Lancioni et al. 2002) showed a positive effect within the sessions, but long-term effects have not been proven. Many studies have methodological concerns due to the population studied, lack of controls, limited number of sessions and the use of qualitative or descriptive data.

Our project was also limited in a number of ways. It was initially a clinical project and not a research project. The project evolved according to events taking place with the families. There is no hard data to support a hypothesis, but only the descriptive results from our own observations, case reports and interviews with the parents and siblings. The novel part of this study, to our knowledge and the literature search, is the participation of the entire family with siblings in the Snoezelen room during sessions and in addition the new possibility for social workers to participate in the room. This new approach will make the social worker see the client and the family in a complete new and different environment. We found that the communication with the family was facilitated in a positive way, emotional issues not before ventilated by the parents came up and it also opened the possibility for the family to see their child in a more positive way.

From the literature search and our contacts at international meetings we find it interesting to note that in Holland the professionals involved with Snoezelen were from the non-medical professions, in United Kingdom and Australia from the nursing profession, the United States psychology and in Israel physiotherapy and occupational therapy. Through this project social workers have been introduced to Snoezelen.

Snoezelen for persons with dementia has been the focus of research by the School of Nursing at Deakin University, Australia (Burns el al. 2000; Cox et al. 2000), where 25 older persons with dementia were studied in the Snoezelen room, in a landscaped garden and in normal living room activity. Their study involved the use of both qualitative and quantitative methods. The quantitative data indicated that the garden and the Snoezelen room were associated with an increase in the ratings of pleasure, but did not suggest any benefit of these two environments over that of the living room, when one-on-one care was given. The interviews with staff and visitors on the other hand revealed pleasure experienced by participants in the garden and Snoezelen room. There was no evidence that one environment was better than any other, but that all improved affect. Differences were found between the qualitative and quantitative components of the study with the qualitative data showing that the garden and Snoezelen room both improved affect in different ways and for different reasons. The qualitative data also gave clear indication that the Snoezelen and garden environments were enjoyed by the care takers and visitors just as much as the residents.

{mospagebreak}Initial contact to the families and schedule for family visits was facilitated through the social worker, who also together with the occupational therapist worked in the Snoezelen room with the entire family.

The sessions were divided into two major parts. The first part (duration 20-40)

In order to review the literature on Snoezelen and social work approach we conducted computerized searches of Medline/PubMed, Social Science Information Gateway (SOSIG), Scirus, APA on-line, PsychCrawler, Ingenta, World Wide Web Resources for Social Workers and Infotrieve.

Acknowledgements

The authors would like to thank the children and their parents of the Lev HaKadosh for their cooperation.

References

Lancioni, G.E., Cuvo, A.J., & O'Reilly, M.F. (2002) Snoezelen: an overview of research with people with developmental disabilities and dementia. Disability and Rehabilitation 24(4), 175-184.

Lindsay, W.R., Pitcaithly, D., Geelen, N., Buntin, L., Broxholme, S., & Ashby, M. (1997) A comparison of the effects of four therapy procedures on concentration and responsiveness in people with profound learning disabilities. Journal of Intellectual Disability Research 41(3), 201-207.

Schofield, P., & Davis, B. (1998) Sensory deprivation and chronic pain: A review of the literature. Disability and Rehabilitation 20(10), 257-366.

Schofield, P., & Davis, B. (2000) Sensory stimulation (Snoezelen) versus relaxation: A potential strategy for the management of chronic pain. Disability and Rehabilitattion 22(15), 675-682.

Shapiro, M., Parush, S., Green, M., & Roth, D. (1997) The efficacy of the

"Snoezelen" in the management of children with mental retardation who exhibit maladaptive behaviours. British Journal of Developmental Disability 43, 140-155.

Shapiro, M., & Bacher, S. (2002) Snoezeling. Controlled multi-sensory stimulation. A handbook for practitioners. Ranana: Beit Issie Shapira.

Baker, R., Bell, S., Baker, E., Gibson, S., Holloway, J., Pearce, R., Dowling, Z., Thomas, P., Assey, J., & Wareing, L.A. (2001) A randomized controlled trial of the effects of multi-sensory stimulation (MSS) for people with dementia. British Journal of Clinical Psychology 60(5), 213-218.Burns, I., Cox, H., & Plant, H. (2000) Leisure or therapeutics ? Snoezelen and the care of older persons with dementia. International Journal of Nursing Practice 6(3), 188-126.Chung, J.C.C., Lai, C.K.Y., Chung, P.M.B., & French, H.P. (2002) Snoezelen for dementia (Cochrane review). Cochrane Database Systematic Review 4, CD003152.Cox, H., Burns, I., & Plant, H. (2000) The impact of using multi-sensory environments as leisure activity on the wellbeing of residents and carers in an aged care facility. Geelong, Victoria, Australia: Rice Village and Deakin University.Hulsegge, J., & Verheul A. (1987) Snoezelen: Another world. Chesterfield: ROMPA.

Kragt, K., Holtkamp, C.C.M., van Dongen, M.C.J.M., van Rossum, E., & Salentijn, C. (1997) Het effect van Snoezelen in de snoezelruimte op het welbevinden van demente ouderen (The effect of sensory stimulation in the sensory stimulation room on the well-being of demented elderly. A cross-over trial in residents of the RC Care Center Bernardus in Amsterdam). Verpleegkunde 12(4), 227-236. (Dutch).

Results

minutes was free activity and the second more structured (duration 15-30 minutes). Case stories are presented to illustrate the positive effects of this approach. Snoezelen can be used with the entire family with the participation of a social worker and add new dimensions to communications.