An Outline of a New Stage of Training for Montessorians
In this article we will discuss the evolution of the use of the Montessori Method as applied with persons with dementia. A growing research base has demonstrated the effectiveness of this approach. We then will describe our initial thoughts for a proposed new level of training and certification for Montessorians, and situations in which persons receiving such training might be employed.
Dementia refers to a set of symptoms, including short-term memory loss and other cognitive deficits—often involving language and reasoning. Dementia is thought to progress in stages, with advanced stages involving more serious deficits. Alzheimer’s disease is thought to be the leading cause of dementia, but other causes such as vascular disease also can create these symptoms. Use of the Montessori Method for persons with dementia and related disorders has evolved over the past two decades (Camp, 2006; 2010; 2013; Camp et al., 1993; Dreher, 1997; Vance, Camp, Kabacoff & Greenwalt, 1996). There are many reasons why using this approach has been shown to have benefits for persons with dementia and their caregivers. The first involves core principles of Montessori’s philosophy and way of living: respect and dignity shown to all human beings.
Sometimes we are asked, “Doesn’t using a Montessori approach mean that you treat older adults with dementia like children?” The obvious answer, of course, is that doing so would absolutely contradict these core principles. We honor the older adult’s life experiences, skills, and expertise obtained over the course of decades of living, and their need to be engaged in meaningful, purposeful activity. Children are not provided ‘busy work’ in a Montessori classroom for the same reason that older adults never should be given activity without a purpose. The key thing to remember is that, simply put, we should treat older adults with dementia in the same way that we wish to be treated.
Most importantly, the systems we create to provide care for persons with dementia are those we will live in if we develop dementia. While the search for a cure for Alzheimer’s disease and other causes of dementia is ongoing (after three decades of research, the cure is not in sight), there is an immediate and pressing need to change the way we think about dementia.
As discussed elsewhere (Mast, Shouse, & Camp, in press), we need to consider dementia as a disability rather than a disease. When we do this, we begin to focus on abilities rather than deficits and to consider ways to utilize capacities to circumvent deficits. It is not surprising, nor coincidental, that Montessori’s original work was with children with disabilities and that her use of rehabilitation techniques became the focus of her educational approach for all children. In the same way, when we work with persons with dementia using the Montessori method, we focus on preparing environments and materials to enable these adults to circumvent deficits and to display competence.
Another Montessori principle which we emphasize is that of equality. This is seen when a Montessori teacher/guide greets a three-year old, stooping down to address the child eye-to-eye. We emphasize the same thing when conversing with an older adult in a wheelchair and for the same reason. In a classroom, where boys iron shirts and girls work with wrenches, and where children from diverse language and cultural backgrounds work cooperatively, the principle of equality is lived each day.
Once again, when we think of dementia as a disability it becomes easier to emphasize the principle of equality when interacting with persons with dementia. When we treat dementia as a disease, as emphasized in a medicalized approach, with its hierarchies of authority and viewing persons as ‘patients,’ the concept of equality can disappear.
This leads to a fourth key concept within the Montessori Method: the creation of a community. In Montessori schools, students work cooperatively to serve meals, care for their environment, etc. Older children assume responsibility for assisting younger children. The community of the classroom is further connected with the larger social community through acts of service, learning experiences off-campus, and a variety of other opportunities to engage with larger social systems.
In a similar way, we emphasize the need to create cooperative communities among persons with dementia, to enable these persons to fill meaningful social roles, and for members of this community to have access and contribute to larger social systems.
History of This Approach A second reason for adoption of Montessori techniques in working with persons with dementia involves a steadily growing research base emphasizing the benefits of this approach, followed by development of training regimens for persons working in the field of dementia-care provision.
The concept of using the Montessori Method for working with persons with dementia was initially proposed by Camp and his colleagues (Camp et al., 1993; Vance, Camp, Kabacoff & Greenwalt, 1996) and independently by Dreher (1997). Camp (2010) describes the evolution of this idea in great detail, with two of his children attending Montessori schools, a wife who became a Pre-K Montessori teacher, and his own experience teaching Child Development at a Montessori training center in New Orleans.
Research in the use of Montessori approaches for persons with dementia first involved training older adults with dementia in nursing home and adult day health-care settings to work with children by training the older adults to present preschool children with Montessori-based activities (Camp et al., 1997; Camp & Lee, 2011; Camp et al., 2004; Lee, Camp, & Malone, 2007). This inter-generational programming was followed by the use of Montessori-based activities directly with older adults with dementia in long-term care and in adult day-health care (Camp, 2006).
Further evolution of this line of research focused on training older adults with mild to moderate dementia to serve as small group activity leaders for other adults with more advanced dementia and to train nursing-home staff to successfully implement such programming for residents (Skrajner & Camp, 2007; Skrajner et al., 2012; in press).
Other international researchers have been actively engaged in demonstrating the benefits of using Montessori-based activities for persons with dementia, including work in Taiwan, Australia, Canada, and Spain. Reports of its successful implementation in dementia-care settings also have come from France, Switzerland, Greece, and Hong Kong.
Trainings to initiate successful implementation of the Montessori Method for persons with dementia have recently take place in Singapore, Malaysia, Ireland, and Italy. Currently, we have been developing a “Social Template Model” for implementing Montessori approaches on a system-wide scale within care settings, emphasizing the need to inculcate the four key principles mentioned above in all aspects of the daily lives of persons with dementia.
Direct Involvement of Montessorians in Dementia Care
The work described thus far has involved attempts to infuse elements of Montessori’s philosophy and approach into dementia-care systems by gerontologists familiar with the Montessori Method in consultation with Montessori teachers and trainers. Recently, we have begun to see direct involvement of Montessorians in dementia-care settings. An example of this approach has been implemented by Montessori International School of the Plains (MISP), a junior and senior high school in Omaha, Nebraska that began in 2010.
The school’s main mission is to provide a Montessori education to any secondary student who desires this non-traditional option. The directors, Tim Fickenscher and Alice Roberts, realized that their students often live far from extended family, such as their grandparents. For adolescents, especially those who may be at risk, the involvement of caring and interested adults can be an important social support and make a real difference in their lives. These relationships encourage academic achievement and graduation from high school (Freedman, 1989).
As a result, based on this precept, the school has formed a partnership with an assisted living community: Hillcrest Mabel Rose in Bellevue, Nebraska. Some persons living at the residence need assistance with activities of daily living due to physical challenges, and others reside in assisted living with memory support. Since the inception of the school, the founders of MISP have worked with Dr. Camp to develop MISP as an inter-generational Montessori Secondary school that can include elders with dementia.
During the last three years, the students and faculty of MISP have conducted Friday classroom sessions at Hillcrest Mabel Rose. Students have formed relationships with residents in both the general assisted-living and memory-support communities. These interactions have been beneficial to both students and residents. Students have experienced having residents as members of their class during specific study projects.
The students provide the computer expertise, while older adults demonstrate a good work ethic and a ‘stick-to-it’ attitude. Older adults also have life experiences that they share with the adolescents. For example, on a study of WWII, one of the residents shared his remembrances of being present at the bombing of Pearl Harbor. Discussions with adults, who are not their parents or teachers, broadens the perspective of our students and creates richer life experiences for all involved.
The use of Montessori approach with the memory-unit residents has taught the students compassion, responsibility, psychology, and a little about the health-care field. The students also are able to use something familiar—Montessori materials—to assist adults with more severe dementia. For example, a group of students were working in the memory community, and one resident in particular was not engaged with anything or anyone.
A student piqued her interested in pouring, using a pretty teapot and cup. Following this activity, the resident became interested in a set of table bells. The student demonstrated how to use them. The resident worked for 40 minutes with the bells. She graded the bells to musical scale, played a simple tune, and accurately remarked that a note was missing. The student later discovered that the resident had been a music teacher.
The staff reported that she rarely speaks or engages in activity. Maria Montessori wrote, “Joy, feeling one’s own value, being appreciated and loved by others, feeling useful and capable of production are all factors of enormous value for the human soul” (Montessori, 1973). The inter-generational experience with Montessori brings benefits to young and old. The adolescents at MISP have the opportunity to see that they make a difference. They see the real life consequences of their work.
A New Stage of Training for Montessorians
As a result of collaboration among the authors of this article, including recent and upcoming presentations at Montessori conferences, we have begun to create a proposed outline for a new stage of training for Montessorians: working with persons with dementia. We envision that this would be an accreditation achieved through coursework and hands-on experience, similar to the process Montessori educators go through before working with elementary or high school students in Montessori classroom settings. We imagine the general outline of the training thus:
Training In Geriatrics/Gerontology. For the most part, persons with dementia are older adults. Thus, it is important for those working in this area to understand physical and psychological issues, especially chronic conditions, related to older adults (e.g., hypertension; arthritis; changing social roles; diabetes;
challenges to mobility, etc.)
Training In Dementia. An older adult with dementia, even in its earliest manifestation, usually has disabilities related to short-term memory loss that are somewhat different than those seen in the school room. In addition, these persons have had decades of life experiences as adults, often in positions of authority and responsibility.
Understanding cognitive and psychological changes that occur across the different phases of the dementia journey as the condition progresses, along with corresponding challenging behaviors related to these changes, will be critical. In addition, while most persons with dementia are older, dementia can occur at any age. This is increasingly evidenced by younger adults (under 60 years of age) being admitted to diverse health-care settings. Providers must be sensitive to the psychological / psychosocial issues of individuals with younger-onset dementia as well as those of persons where
dementia’s onset occurs later.
In another example, we are also seeing the importance of understanding the differences between dementia and depression in the aging adult. Often times, elderly individuals are misdiagnosed: Is it depression or dementia? There is evidence that depression in people with dementia is seriously under-recognized and under-treated. This is mainly due to the challenges in relying on self-report in this population. The following guide is used for caregivers to better
understand the differences:
- Symptoms of Depression
- Symptoms of Dementia
- Mental decline is relatively rapid
- Mental decline happens slowly
- Knows the correct time, date, and where he or she is
- Confused and disoriented; becomes lost in familiar locations
- Difficulty concentrating
- Difficulty with short-term memory
- Language and motor skills are slow but normal
- Writing, speaking, and motor skills are impaired
Training in translation of Montessori techniques to dementia care. The good news is that training in the Montessori Method is readily translatable into good practice in dementia care. Research has shown that a helpful model in guiding clinical care for individuals with dementia considers needs from three perspectives: cognitive and functional abilities; motor function; and behavioral and psychological issues (Camp, 2010).
The Montessori Method in dementia care is an effective non-pharmacological approach to providing quality care and meaningful activity for this population. Use of templates, external aids, building on existing knowledge, categorization, breaking down tasks into steps, and having purpose in activity with immediate feedback are beneficial at any age. While persons with dementia may have difficulty remembering recent life episodes, they still show increasing improvement when practicing procedures. For example, persons with dementia can use standard Montessori techniques to learn how to use chopsticks, even if they do not remember that they practiced with them in the past. Montessori’s statement that they will learn through their hands is especially relevant here.
Online Training. Much coursework in such a program could be completed through online training. Existing courses in geriatrics and gerontology could be utilized. For example, Bellevue University has a course titled Normal Aging and Disease Change, which is part of its Certificate of Completion in Nursing Home Care. In addition, online training has been provided for some time from Montessori training centers, and creation of new coursework for translation of the Montessori Method, as applied to dementia populations, could be provided through existing infrastructure, such as the Montessori Leadership Courses Online provided by The
Montessori Foundation.
Summer Hands-On Training. We also envision required ‘hands-on’ application of distance-training content. A first group of trainees could take advantage, for example, of the existing relationship between Montessori International School of the Plains and Hillcrest Health Services to create summer internships. Over time, the number of sites and times for such experiences could expand. Work Settings for Trainees
Traditional work settings for dementia care include the home of persons with dementia, adult day centers, assisted living, assisted living with memory support communities, and skilled nursing residences. There also is need for implementation of this approach in hospitals and other medical settings, such as acute care, post-acute care, rehabilitation in-patient and rehabilitation outpatient care.
Of course, with the creation of a new stage of training for Montessorians, we envision the creation of new forms of dementia care, including learning centers where persons with dementia can come to acquire new experiences, new abilities, and renewed capacity to maintain meaningful social roles within communities. Such new forms of care may emerge from within existing models or may become free standing entities.
Regardless of the setting, providers must assist individuals with dementia by encouraging meaningful activities that can be tailored to the individual. Providers (in all settings) should encourage social interaction and assist individuals to maintain their connections with their environments, both physical and social.
Through the use of the Montessori Method, these individuals may enjoy a higher quality of life, show an increase in improved functional ability and engagement, as well as a decrease in challenging behaviors. (Remember that the first Montessori school was created for children with ‘challenging behaviors.’)
Conclusion The primary message we wish to convey is that Maria Montessori’s teachings and philosophy are highly relevant today and in the future as transforming agents for the way we deal with dementia and related disorders as individuals and as a
society. We envision persons who have worked in Montessori classrooms applying their skills, passion, and ways of
living to a new group of person who are desperately in need of these gifts. The first author, after finishing three days of training in this approach in the south of France, saw a hand raised by a graduate student in psychology about to go into a nursing home work setting. She said, “Now I understand. This is about changing civilization.” This, as always, is the true meaning and legacy of Maria Montessori’s lifework.
Authors:Cameron J. Camp, Anna Fisher, Ph.D.,
Tim Fickenscher, M.Ed. & Alice Roberts, M.Ed.
References
- Camp, C. J. (2006). Montessori-Based Dementia Programming™ in long-term care: A case study of disseminating an intervention for persons with dementia. In R. C. Intrieri & L Hyer (Eds). Clinical applied gerontological interventions in long-term care (pp. 295-314). New York: Springer. Camp, C. J. (2010). Origins of Montessori Programming for Dementia. Non-Pharmacologic Therapies in Dementia, 1(2): 163-174.
- Camp, C. J. (2013). The Montessori approach to dementia care. Australian Journal of Dementia Care, 2(5), 10-11.
Camp, C. J., Foss, J. W., Stevens, A. B., Reichard, C.C., McKitrick, L. A., & O’Hanlon, A. M. (1993). Memory training in normal and demented populations: The EIEIO model. Experimental Aging Research, 19, 277290. - Camp, C. J., Judge, K. S., Bye, C. A., Fox, K. M., Bowden, J., Bell, M., et al. (1997). An intergenerational program for persons with dementia using Montessori methods. The Gerontologist, 37, 688-692.
- Camp, C. J., & Lee, M. M. (2011). Montessori-based activities as a trans-generational interface for persons with dementia and preschool children. Journal of Intergenerational Relationships, 9, 366-373.
- Camp, C. J., Orsulic-Jeras, S., Lee, M. M., & Judge, K. S. (2004). Effects of a Montessori-based intergenerational program on engagement and affect for adult day care clients with dementia. In M. L. Wykle, P. J. Whitehouse, & D. L. Morris (Eds.),Successful aging through the life span: Intergenerational issues in health. New York: Springer, (pp. 159-176).
- Dreher, B. B. (1997). Montessori and Alzheimer’s: A partnership that works. American
Journal of Alzheimer’s Disease, 12, 138-140. - Freedman, M. (1989) Fostering intergenerational relationships for at-risk youth. Children
Today, 18, 10-15. Lee, M. M., Camp, C. J., & Malone, M. L. (2007). Effects of Intergenerational Montessori-based Activities Programming on Engagement of Nursing Home Residents with Dementia. Clinical Interventions in Aging, 2(3), 1-7. - Mast, B. T., Shouse, J., & Camp, C. J. (in press). Person-centered assessment and intervention for people with dementia. In B. Mast & P. A. Lichtenberg (Eds.) American Psychological Association Handbook of Clinical Geropsychology. Washington, D.C. APA.
Montessori, M. (1973). From childhood to adolescence. New York, Schocken Books. - Skrajner, M. J., & Camp, C. J. (2007). Resident-assisted Montessori programming (RAMP™): Use of a small group reading activity run by persons with dementia in adult day health care and long-term care settings. The American Journal of Alzheimer’s Disease & Other Dementias, 22(1), 27-36.
- Skrajner, M. M., Haberman, J. L., Camp, C. J., Tusick, M., Frentiu, C., & Gorzelle, G. (2012). Training nursing home residents to serve as group activity leaders: Lessons learned and preliminary results from the RAP project. Dementia, 11: 263-274.
Skrajner, M. M., Haberman, J. L., Camp, C. J., Tusick, M., Frentiu, C., & Gorzelle, G. (in press). Effects of using nursing home residents to serve as group activity leaders: Lessons learned from the RAP project. Dementia. Published online before print August 27, 2013. - Vance, D., Camp, C. J., Kabacoff, M., & Greenwalt, L. (1996). Montessori methods: Innovative interventions for adults with Alzheimer’s disease. Montessori
Life, 8, 10-12. Outline of a New Stage of Training for Montessorians - Cameron J. Camp, Ph.D. (Center for Applied Research in Dementia) Anna Fisher, Ph.D. (Hillcrest Health Services)
- Tim Fickenscher, M.Ed. (Montessori International School of the Plains)
- Alice Roberts, M.Ed. (Montessori International School of the Plains)
Montessori Leadership / August 2014/ p 22
