Occupational therapy services in Malta have for many years been provided through a ‘caseload’ approach. This means that children diagnosed with a ‘problem’ are referred to a service and are usually seen in a clinical setting with a focus on direct intervention with the child. Along the years, in North America, Canada and Europe, occupational therapy services for children have been contextualised to the school setting – the place where children spend a large part of their day.

Occupational therapy best practice in schools focuses on a workload model that is in keeping with a whole-school approach. The aim is to support all children in the school system and in the classroom to participate. Therefore, it is not only children who have a ‘diagnosis’ that benefit, but a wider range of vulnerable children whose participation is disrupted by an array of biopsychosocial factors.

Tiered models of intervention have been studied and are being used internationally in countries such as North America, Canada, and throughout Europe (Bazyk et al., 2020; Missiuna et al., 2016; Lynch et al., 2021). The tiered model is a way of working that addresses the needs of all children to different extents.

The tiered model is a way of working that addresses the needs of all children to different extents. (Reproduced with permission from Bazyk, 2020)

Tier 1 is about universal intervention, which includes core instruction and intervention with the whole class. It is about education for all within the general curriculum. Principles of universal design (Meyer et al., 2014) for learning are used by teachers, therapists and administrators in both the school and classroom to enable children to access the curriculum.

Tier 2 constitutes targeted intervention for children at risk, and may include supplemental intervention with groups of children with similar needs and who have not been served by a universal approach. This tier involves differentiation of the curriculum.

Tier 3 involves accommodation, meaning intensive intervention on an individual basis for children with identified additional needs. This involves individual education-oriented interventions. Tier 3 is usually for those students who have been diagnosed with more complex needs and who usually have an Individual Education Plan (IEP).

Using a workload approach with a focus on collaborative consultation promotes knowledge exchange and capacity building of the classroom teacher, learning support educators and the parents, rather than focusing on the child in isolation. With such a model, educators and therapists are co-teachers and co-learners. The whole school, rather than the individual child, is the client, and intervention occurs in the classroom, the hallway and the playground, with all children. Hence, children at risk of falling behind in the school system benefit from such a model. There is no need for a diagnosis or a ‘label’.

Aspects of the tiered model unique for the Maltese early years context were identified through a study that I conducted as part my PhD in Occupational Science: Tier 1 intervention built educators resilience in delivering their curriculum; Tier 2 intervention provided a way forward in supporting children with ‘hidden’ needs; while Tier 3 was unique in the collaboration between the occupational therapist and class teacher in educating students with a statement of needs.

The importance of working with school leadership was an important finding in my study, and it forms the basis for collaborative work in schools.

My research contributed to the international body of evidence on collaborative consultation and also provided recommendations as to how a model of school-based occupational therapy tiered intervention can be implemented in Maltese schools, specifically in the early years. The study suggests the way forward in developing school-centred practice to support the participation and inclusion for all children in school and society.

We need to create a paradigm shift in the provision of therapy services in Malta and expand service delivery from a direct 1:1 approach to a workload model using collaborative consultation, coaching, co-teaching and modelling in context.

We need a paradigm shift in the provision of therapy services in Malta and expand service delivery from a direct 1:1 approach to a workload model

Aspects of this research, including a whole-school approach to working in the kindergarten years, are already being put into practice through university/community partnerships with the National School Support Services (NSSS) and other schools.

Nathalie Buhagiar is a resident academic at the Department of Occupational Therapy at the University of Malta’s Faculty of Health Sciences. She is an expert in paediatric occupational therapy, having worked in both healthcare and educational settings locally and abroad for over 30 years. For her PhD she obtained support from the Malta Government Scholarship Scheme (MGSS) and the University of Malta. To obtain literature sources cited in this article and more information on this approach, e-mail the author at nathalie.buhagiar@um.edu.mt.