Published on February 12th, 20140
Tumbling Together: An Innovative Approach to Interprofessional Paediatric TherapyBy James Wintle, Cécile Loiselle and Jean Chamberlain This article was originally published in Occupational Therapy Now, Volume 15.2. Please note that the article has been edited for this publication.
The importance of interprofessional collaboration within the health field has long been established (Barr, 2002). Tumbling Together, a unique paediatric program, is offered by an interprofessional team composed of an occupational therapist, a speech-language pathologist (S-LP), a children’s mental health professional and a certified gymnastics coach, as well as pre-service professional students and volunteers. The mission of Tumbling Together is to deliver therapy to children with a variety of developmental and physical challenges by using movement, social interaction and play. We emphasize play because it is through play that children learn skills to support their roles as players and, later on, other meaningful occupational roles such as friend or student (Burke, 1993; Rodger & Zivianni, 1999).
Our vision is to enhance the social participation and relationships of the children in the program. Some of the challenges these children face include:
- difficulty with age-appropriate social interactions/play
- poor use of language in a social setting
- gross motor difficulties/incoordination (although participants must be able to walk)
- poor oral-motor coordination
- poor or weak posture/trunk control
- poor body awareness
- challenging sensory profile (avoidant, overreactive)
The children’s challenges are identified by parents or by their previous or existing therapists. Many of the children also experience difficulty with self-regulation. Self-regulation involves the ability to stay calmly focused and alert (Shanker, 2010) as well as the ability to manage one’s energy states, emotions, behaviours and attention in ways that are socially acceptable and help to achieve positive goals (Shanker, 2012). Self-regulation has been shown to be a predictor of academic success (Shoda, Mischel, & Peake, 1990), and poor self-regulation has been linked to risk-taking (Crockett, Raffaelli, & Shen, 2006) and poor health (Bandura, 2005; Grossarth-Matickek & Eysenck, 1995; Riggs, Sakuma, & Pentz, 2007). The more a child can stay calmly focused and alert, the better he or she can integrate diverse incoming sensory information, assimilate it and sequence his or her thoughts and actions (Shanker, 2010). Self-regulation is thus an essential skill we encourage in the Tumbling Together program.
Tumbling Together addresses a child’s needs by engaging him or her in physical activity and social interactions while building his or her capacity to self-regulate. Therapy is structured around small groups of four to seven children, ranging from three to five years of age.
An occupational therapist, S-LP or children’s mental health professional will refer children to Tumbling Together. We also accept referrals from other agencies. Although some children may have a formal diagnosis (e.g., autism spectrum disorder, Down syndrome, hemiplegia, speech/language disorders), a formal diagnosis is not a requirement for enrolment.
The entire program consists of 11 sessions. The first session is an hour-long information and preparation meeting to familiarize parents and caregivers with the program. Each session thereafter is 45 minutes long and takes place at a local gymnastics club. The first three children’s sessions are focused on orientating children to the program. These sessions are also an opportunity for the interprofessional team to assess each child and make program adjustments if necessary.
With parent or caregiver input, the team sets goals in five specific domains:
1. motor skills
3. functional communication
4. school readiness
The team then writes the goals in a Goal Attainment Scale format for weekly scoring (King, McDougall, Palisano, Gritzan, & Tucker, 2000).
In all activities, the children are supported by a member of the interprofessional team who first demonstrates how to perform each activity and encourages and praises the children’s participation. Therapists also co-regulate participants, providing models or prompts for sensing and communicating what it means to be calm, alert and focused. Over the 10-week period, the amount of support the team offers is gradually reduced so that each child can achieve his or her maximum independence. As adult support is minimized, children increasingly act as peer models for each other. Each group of children is carefully selected to ensure that membership includes both ‘expert’ and ‘novice’ players (Wolfberg, 2003). Combining experts and novices in areas of communication, self-regulation and gross motor function allows for age-appropriate peer models in each target area. It also provides children with the opportunity to experience success in some domains while still facing challenges in other areas.
The children’s sessions
All sessions begin with the children sitting on a bench and waiting while the gymnastics coach takes attendance. Members of the interprofessional team use this opportunity to teach awareness and the language of steps in an entry sequence. They also “scaffold” for distress-free separation from parents and self-regulation while the children wait to start. Scaffolding involves providing the appropriate types and amount of support to children and parents, as well as grading it as needed. After this, children enter the gym space for “circle time”, which includes simple songs that encourage the participants’ use of speech. This is followed by a line-up game where children take turns being in the front, middle and back of the line — an important school-readiness skill. Parents observe sessions through a window, removing the potential distraction of having parents in the same room while still allowing them to observe and experience their child’s progress.
Next are the three motor circuits on gymnastics bars and mats. Circuits are designed to offer vestibular stimulation, such as flipping over a bar with the assistance of the gymnastics coach, and proprioceptive input, such as jumping off of mats from different heights. Each circuit contributes to building muscle strength and improving motor planning and coordination. We modify the circuits over the course of the program to progressively challenge the children and help them maintain their alertness. Importantly, the circuits require children to wait for their turn. When a child finishes an activity within a circuit, he or she will turn to the waiting participant and call out her name, saying “your turn”. The peer responds by saying “okay” before proceeding through the activity.
During the motor circuits, the gymnastics coach takes children aside one at a time to use the trampoline. The trampoline is a sensory-rich activity that challenges the children’s vestibular and proprioceptive systems. During the last five minutes, children and team members form a “closing circle” and play a simple game such as “duck, duck, goose”. The final activity is choosing the photograph of another participant or a favourite piece of gym equipment. This photo is taken home and returned at the next session. The purpose of this activity is to encourage conversation between children and their parents or caregivers and to help participants learn their peers’ names.
Throughout the program we increasingly integrate parent or caregiver engagement by asking parents or caregivers to identify a moment of pride in their child each week and to join in the fun of the closing circle games. At the end of each therapy session, therapists meet to discuss the progress of each participant and to score their goals using the Goal Attainment Scale.
Consistently positive feedback
Following the completion of the 11-week program, we provide parents with a report that summarizes their child’s progress and outlines strategies to use at home, day care or school to further promote goal attainment. We also ask parents to fill out a feedback form. The program feedback we have received is consistently positive and most parents comment on the noticeable progress their child has made. The wealth of positive anecdotal evidence in support of this interprofessional program, as well as improvements in Goal Attainment Scale scores, highlight its value. We hope that our success with Tumbling Together will encourage other therapists to collaborate and develop innovative and interprofessional approaches to paediatric therapy.
Bandura, A. (2005). The primacy of self-regulation in health promotion. Applied Psychology: An International Review, 54(2), 245–254.
Barr, H. (2002). Interprofessional education today, yesterday and tomorrow: A review. London: LTSN HS&P.
Burke, J. P. (1993). Play: The life role of the infant and young child. In J. Case-Smith (Ed.), Paediatric occupational therapy and early intervention (pp. 198–224). Boston: Andover Medical Publishers.
Crockett, L. J., Raffaelli, M., & Shen, Y. L. (2006). Linking self-regulation and risk proneness to risky sexual behavior: Pathways through peer pressure and early substance use. Journal of Research on Adolescence, 16(4), 503–525.
Grossarth-Maticek, R., Eysenck, H. J. (1995). Self-regulation and mortality from cancer, coronary heart disease, and other causes: A prospective study. Personality and Individual Differences, 19(6), 781–795.
King, G. A., McDougall, J., Palisano, R. J., Gritzan, J., & Tucker, M. A. (2000). Goal attainment scaling: Its use in evaluating pediatric therapy programs. Physical & Occupational Therapy in Pediatrics, 19(2), 31–52. doi:10.1080/J006v19n02_03
Riggs, N. R., Sakuma, K. K., Pentz, M. A. (2007). Preventing risk for obesity by promoting self-regulation and decision-making skills: Pilot results from the PATHWAYS to health program (PATHWAYS). Evaluation Review, 31(3), 287–310.
Rodger, S. & Ziviani, J. (1999). Play-based occupational therapy. International Journal of Disability, Development and Education, 46(3), 337–365.
Shanker, S. (2010). Self-regulation: Calm, alert, and learning. Education Canada, 50(3). Retrieved from http://www.cea-ace.ca/education-canada/article/selfregulation-calm-alert-and-learning
Shanker, S. (2012) Self-Regulation. Retrieved from http://www.ccyp.wa.gov.au/forumThinker.aspx?cId=568
Shoda, Y., Mischel, W., & Peake, P. K. (1990). Predicting adolescent cognitive and self-regulatory competencies from preschool delay of gratification. Developmental Psychology, 26, 978–986. Wolfberg, P. J. (2003). Peer play and the autism spectrum: The art of guiding children’s socialization and imagination (Integrated Play Groups (IPG) Field Manual). Shawnee Mission, KS: Autism Asperger Publishing Company.
About the authors:
BSc, BEd, MEd, MScOT
James is a researcher at Queen’s University. His research focusses on interprofessional education and inclusive learning environments.
BSc (O.T.) , O.T. Reg. (Ont.)
Brockville General Hospital & Private Practice
Although she has worked 30+ years with children with special needs, Cécile’s experience has been that the elements of Tumbling Together have generated absolutely THE most success in therapeutic intervention with preschool clients – not to mention the most fun!
M.A., Reg. CASLPO, Speech/Language Pathologist
Language Express @ Brockville General Hospital
Jean Chamberlain has been working with families and their children with communication disorders at Brockville General Hospital for 30 years. As her clients have become younger she has developed a special interest in the importance of incorporating movement and self-regulation into speech/language therapy activities.