A book in the making Here is the first chapter of a practical manual to support task oriented movement training for children. For updates and discussions please join the TOMT Facebook group.
Modern physical therapy for children is informed by the principles of child and family centered practice and a coaching approach to intervention. Task oriented movement training (TOMT), embedded withing a child and family centered practice, provides a principled approach to assessing and training tasks that the child and family wish to improve or master.
Evidence for practice
Task, activity and participation oriented approaches are now the recommended approach to intervention for children with DCD, as well as infants and children cerebral palsy.
"Activity-oriented or participation-oriented approaches should involve family, teacher, significant others, and/or environmental support to cascade and promote essential opportunities for practice and generalization. This is necessary to give enough opportunity for motor learning and consolidation of skills."
"Formally investigated activity-oriented or participation-oriented approaches, based on this and the previous review, include but are not limited to task-specific training, NTT, and cognitive orientation to daily occupational performance approach (CO-OP)."
The new International clinical practice recommendations for intervention strategies emphasize activity and participation-oriented approaches to intervention.
R 22 If an intervention is to be provided then we recommend that activity-oriented and participation-oriented approaches be used as a means to improve general, fundamental, and specific motor skills in individuals with DCD.
Neuromotor Task Training and SfA TOMT
Neuromotor Task Training (NTT) is one approach that shows good evidence for effectiveness. The NTT approach starts with identifying the tasks that the family and child would like to work on and setting goals for task performance.
This is followed by an in depth analysis of task performance for the identified tasks, taking into account the interaction between the individual (child), the task and the environment (T-I-E).
The child's ability to perform a task successfully may be limited (constrained) by one or more factors within the task, the child or the environment.
NTT recommends a formal process of identifying the factors that constrain or aid the child and the use this knowledge to adapt the task or the environmental demands so as to make the task easier and allow the child to succeed. With practice the demands are increased until the child is able to perform the task
The SfA Task Oriented Movement Therapy approach follows the same basic structure without the formal hypothesis generation and process of testing the hypotheses to identify the limiting factors.
TOMT also places more emphasis on understanding the behavioral and temperament factors that influence motor learning and task engagement, and using the OPTIMAL guidelines for enhancing task learning.
Family centered practice and task oriented training
The evidence for the use of task oriented movement training for improving movement skills is now strong. This applies to infants with developmental delay, children with DCD and cerebral palsy (Blank et al 2019).
But for the most part physical therapy for children encompasses more than training motor skills, including problem solving around practical issues with mobility and activities of daily living, advocacy, understanding family physical and financial circumstances and limitations, and the building of relationships with the child and family members, and so on.
In modern models of pediatric physical therapy is child and family centered practice is a guiding principle, along with collaborative goal setting and coaching models of intervention.
The question arises: where and how does task oriented movement therapy and training fit into this broad conception of modern physical therapy practice and clinical reasoning when working with children?
Steps in implementing task oriented training within a family centered model
► As a first step therapist meets with the child and family, allowing for identification of movement related issues that the child and family would like to address.
Thinking about daily routines and tasks (at home, in the classroom and playground, out in the community) is a useful way to identify the tasks the child has not yet mastered (and would like to master).
One good outcome that emerges from making a list of mastered and not-yet mastered tasks is that for the most part the things that a child can do usually outnumbers the things they cannot do.
Tasks are identifiable units of activity and participation
► The next step is to collaborate with the family to identify the tasks that need attention and to write goals that are realistic and achievable.
► This is followed by figuring out the best way to achieve each goal.
- This may relate to making changes in the environment or daily routines, referrals to other services and so on.
- Some goals can be achieved by implementing task oriented movement training.
The cornerstones of TOMT
1 Tasks can be defined as units of action that have a beginning and an end that are oriented towards achieving a goal.
Activity and participation are enhanced or constrained by a child's ability to perform one or more tasks within a given environment.
2 A child's behavior and ability to perform a task is determined by the interaction between the task (T) the individual child (I) and the environment (E).
Adopting T-I-E thinking allows the therapist to identify aspects of the task and the environment that enhance or constrain a child's ability to succeed, improve or master a task.
3 Not-yet thinking opens possibilities
Learning a new task takes practice, persistence, some success and as well as lots of failure. When it comes to tasks that are difficult, it helps to shift one's thinking from "I cannot do this - it is too difficult" to I cannot do this YET - it needs practice." In a TED talk Carol Dweck talks about the power of believing that you can improve
4 The OPTIMAL approach to motor learning
The Optimizing Performance Through Intrinsic Motivation and Attention for Learning (OPTIMAL) theory of motor learning (Wulf et al 2016) proposes that:
- Expectations for positive experience/outcomes benefit motor performance and learning.
- Conditions that support performer autonomy benefit motor performance and learning.
- An external focus of attention on desired movement effects is consistently effective.
- Motivation and attentional focus contribute to connectivity and goal-action coupling.
5 Cognizance of the impact of temperament and behavioral inhibition as a temperament style on experience and willingness to engage in a task.
Temperament drives a child's willingness to take on or avoid challenges, persist in the face of failure and tolerate the strong sensations that arise from the body in effortful physical activity. Read more
Steps in implementing task oriented movement training
1 Start with a task that the child and family would like to improve.
If a task has a series of different actions, such as getting dressed, start by working on each one separately.
2 Identify the structure of the task and all the T-I-E elements that contribute to task performance
I find that performing the task slowly, in a very deliberate way, with careful attention to each movement is a very helpful way to identify the different movement components of a task.
3 Identify the visual information that is needed at each step along the way.
Gathering visual information in a very systematic manner before the task is initiated helps to compensate for the poor online visual monitoring.
4 Think about ways the task can be adapted to make it easier to perform ie adapt the task demands.
Start easy - progress to more difficult.
Catching a soccer ball is easier than catching a tennis ball; putting on trousers with an elastic band is easier than a pair with a zip; pouring milk from a half empty bottle is easier that pouring from a full bottle; walking down a flight of three steps is easier than starting at the top of a long flight of stairs.
5 Practice the adapted task - provide support and encouragement as needed.
Let your child try performing the task without help to start with. Children need experience with working things out for themselves.
Notice what aspects of the task are particularly difficult and lead to failure. Provide help if needed.
6 Provide task specific praise
Praise that identifies the specific actions that were well done is more effective than a general statement such "Well done" or "Good job".
Instead talk about the action that was well performed: "You poured without any spilling" is more effective than "You are good at pouring."
Feedback such as "You caught the ball 6 times out of ten. Well done." provides the child with a sense of achievement and a measure of success.
A word about sensory information and task performance
The movement brain uses sensory information from the body (muscles, joints, skin, vestibular system) and from the environment (visual and sound information) to plan movements, to adapt the movements during execution of the task, and evaluate the outcome of the action.
Before we execute a movement we gather information from the environment to plan the movement: how far do I need to move my hand to reach the cup; how high is the step I want to step up onto; is the dog standing in front of me going to move as I approach?
During execution of the movement we use sensory information to check the progress of our actions: is my hand moving in the right direction; have I lifted my foot high enough to get it onto the step; has the dog moved?
In neurotypical children sensory information reaches the areas of the brain involved with motor planning and evaluation, rapidly and concurrently, and information is selected and integrated in a timely manner that allows for ongoing adjustments in the movement.
In children with movement difficulties the movement brain processes this information in a different way. For instance in autism the differences in connectivity in the brain means that information from the visual areas of the brain take longer than proprioceptive information to reach the movement brain. As a result children with autism rely more on information from the the muscle and joint sensors (proprioceptors) when planning and executing movements.
Task specific training allows children with movement differences to compensate for these differences in sensory feedback. This compensation is task specific.
Increasing proprioceptive feedback is not the answer
Sensory based treatment strategies often recommend a range of strategies to increase proprioceptive feedback to improve motor control. This is not useful: in fact children with movement difficulties mostly have heightened sensitivity to information coming from the joints and muscles.
It is more important to train the movement brain to use the available proprioceptive information more effectively for motor planning, on a task by task basis.
Lola learning to cut out a circle: a TOMT session
Lola, 8 years, is having difficulty cutting out a circle with a pair of scissors. It takes forever to complete the task and the end result is jagged and not pleasing.
Step 1: Understanding the task
To understand the task I perform it slowly, with careful attention to every aspect of the task, and notice how:
Step 2: Watch Lola performing the task
Step 3: Simplify the task
I need to simplify the task to allow Lola to succeed.
Step 4: Provide verbal cues
To jog her memory, I instructed Lola to use verbal reminders.
With these verbal reminders Lola managed to cut up several strips of card quickly and neatly along the lines. We used the squares that we cut to make a mosaic.
Step 5: Provide encouragement and feedback
Step 6: Make the task a little more difficult - cutting diagonally
In the next training session Lola practiced cutting along diagonal lines drawn on a strip of paper. This is quite tricky because the strip of card needs to be aligned at an angle to the blade of the scissors.
It took some time and quite a lot of frustration before Lola got this right. Using the verbal instructions helped her focus her attention and with encouragement from me she stayed on task and persisted.
When she finally mastered this tricky work she was elated. Success!
Now it was time to practice cutting out a circle
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