NTT Workshop in Cape Town
31 August -2 September 2018
Presenters: Prof Bouwien Smits-Engelsman and Dr Eugene Rameckers
Neuromotor Task Training (NTT) is a context and task based and constraints-led approach to intervention for children with developmental movement conditions.
NTT is based on the understanding that a child's ability to successfully achieve a desired movement goal resides in the interaction between the child, the task and the social and physical environment (C-T-E).
A toddler's ability to climb up onto a chair, turn around and sit down safely is determined by the height of the chair, the size of the seat (context), the possibilty to put on the arm onto the seat (child), back of the chair (context), combined with body length and weight of the child (child), influencing the need of a typical adapted strategy to climb a chair and the amount of needed muscle strength of legs and arms to climb the chair, lift the body. Based on the cognitive possibilities the child is able to adequately plan the climbing on a chair from standing position to a seated position on the chair.
Climbing up onto a dining room chair takes practice and it is the social environment that plays an important role in encouraging and providing opportunities for the toddler to practice this task.
If the child is of a nervous disposition, he will require extra encouragement to do this slightly dangerous task. Another child, who is confident and enjoys climbing and clambering will be climbing up onto any available raised surface, including moving the chair next to a table, then climbing up from the chair onto the table.
Overview of NTT process
NTT starts with a careful analysis of the factors within the C-T-E interaction, starting with the environment and task analysis, that contribute to the successful achievement of a task goal. Some factors may limit or hamper the ability to perform a task, while other factors may enable or promote successful performance.
The main goal in the NTT approach is to identify the factors within the C-T-E interaction that limit or enable/promote task execution, and then provides opportunities to practice the task by adapting the task and environment and goals to allow the child to succeed.
In keeping with the principles of child and family centered intervention, the NTT therapy process starts with an initial interview in which the specific needs of the child and the family, are identified and then collaborating with them to select the tasks that will be addressed in therapy:
Step 1:Observation and problem identification
The therapist identifies the tasks relevant to perform the requested needs.
Step 2: Selecting the tasks that the child, parents, teachers would like to work on in therapy.
In collaboration with the therapist, the child and family identify which tasks that will be addressed in therapy. For each task goals are identified which clearly describe what the child would like to be able to do, including where and when.
Step 3: Identification of task constraints
For each selected task, there is a systematic approach to perform the task performance analysis and to detect the limiting factors and to enable task performance (constraints) in different contexts, and based on this information an intervention strategy is designed according to NTT principles.
Step 4: Intervention
The child attends regular therapy sessions where opportunities to practice the task at increasing levels of difficulty and complexity, in a task relevant environment that optimally supports learning. As the child’s ability improves, tasks are progressed by increasing task difficulty and complexity .
NTT process for each of the selected tasks
The core aspect of Neuromotor Task Training is an in-depth analysis of the reasons why a child has difficulties in executing a particular task (constraints), and then devising practice/learning opportunities with adapted goals that allow the child to overcome these constraints and achieve success, with progressive increasing the task complexity;
The process for each task includes:
1 Detailed formulation of end goals: what, how, where, when.
2 Task performance analysis: based on observation of the child's performance of the identified task goals.
3 Based on this observation the therapist identifies the possible constraints limiting task performance and successful achievement of the goal.
4 The next step is to devise a set of adapted assessment tasks that change the task demands, allowing the identification of the limiting constraints.
5 Once the limiting constraints have been identified, the next step is to design training activities that provide the child with opportunities to overcome these limitations.
This is done by changing the environment & task (which changes the goal for each practice task) and then as the child's abilities improve, progressively increasing the task complexity.
Learning to catch a ball
Larry who is 6 years, has been diagnosed with DCD has been referred for therapy to improve his motor skills. In particular he experiences difficulties with ball skills and in the initial assessment Larry identified ball catching as a task he really wanted to work on. He said his friends are all good at catching a tennis ball. In PE lessons they play rounders, and he keeps missing the ball and his classmates get annoyed with him.
Larry will be able to successfully catch a tennis ball thrown from different locations and different distances at least 70% of the time.
Task performance analysis
The first step is to observe task performance in several environmental conditions. The second step is to identify the level of task performance and environmental condition in which the child can perform the task for 70% or more with succes. The third step is to assess possible constraints that Larry experiences when catching a tossed ball.
The therapist observes Larry catching a tennis ball that is tossed from a 5 meter distance to vary the environment to detect the level of complexity, the therapist passes him in different locations in his peri-personal space. The velocity of the ball is also changed from fairly slow to a fast, hard throw.
Larry gets ready to catch the ball by cupping his hands together and holding them in front of the body at waist height.
Larry manages to catch the ball only when it is tossed slowly and can be caught in front of his body with two hands. When to ball approaches fast he turns his head away.
The therapist also notices that Larry does not pay attention to her actions when she tosses the ball to him. He does not respond to feigned tosses.
1. Larry has not enough experience in ball catching. 2. Variation in ball direction is difficult for Larry, especially when high curved flight path of the ball has been used. 3. Specific problem has been seen in focusing on the ball in the moment of timing the catching. 4. Larry is very easily distracted performing ball catching NTT therapy
The therapist introduces several activities that assess Larry's ability to catch the ball, including predicting flight path, catching a bounced soccer sized ball so that it bounces in different locations, and requires ball tracking for successful catching, catching a tossed soccer sized ball in different locations with repeated instructions to "Get ready. Watch me".
Initially Larry has difficulty with each of these tasks - but with some practice he starts to make better amount and performance of catches.
Larry's goal is quite ambitious, but certainly achievable with lots of practice of tasks of ever increasing difficulty that progressively increases difficulties in catching, related to ball size, repetitions to improve endurance, distance, relative position of ball tosser, moving around when catching and inclusion of more people in the game to start simulating a real game of rounders.
Practice tasks will be increased in complexity upto the level that Larry will be provided with a challenge, but he is still able to succeed most of the time.
Practicing ball catching will be combined with ball throwing activities, another skill that Larry would like to improve.