®
The Alert Program for Self Regulation
an evaluation of a group based intervention for children
attending a child and adolescent mental health service (CAMHS)
Cremin
Lamb
O’Connell
1Discipline of Occupational Therapy, Trinity College Dublin,
2.Lucena Clinic, Rathgar 3.Mater Child and Adolescent Mental Health Service.
1
K .,
Introduction
In CAMHS children who have a primary diagnosis of
ADHD, high functioning autism and Aspergers
syndrome frequently have comorbidity with self
and sensory regulation disorders(Dunn & Bennet,
2002 and Dunn et al. 2002) Treatment options can
include medication, parenting groups and
occupational therapy. One of the programs
frequently offered by occupational therapists is
the Alert Program®. This program is a cognitive and
experiential approach based on sensory integration
principles designed to be used with children with
self and sensory regulation difficulties. The
application of the program to groups of children
with emotional disturbance, particularly in the
classroom setting has been shown to be useful.
(Barnes et al. 2003,Colangelo, 2008; Maas, Mason
& Candler, 2008 and
Salls & Bucey, 2003).
However, these reports do not have any research
evidence for its merits. The difficulties in
researching the effectiveness of the program most
likely lie in its flexibility of implementation and
the fact that many of the children participating in
the program will also be involved in other
therapies.
Aims
This research project aimed to examine if a group
of children participating in a 6 week Alert
Program® ;
1) Made any gains in sensory processing,
attention, behaviour and social skills (at home
and school) as measured by standardised
measures.
2) Achieved individualised goals set around self
regulation and related behaviours as measured
by Goal Attainment Scaling (GAS)
Methods
An experimental pre-post test design was utilised.
Inclusion criteria for the study were that the child
was not on medication, parents were not
attending parenting group at time of program, the
child was between 6 and 12 years and assessed by
CAMHS team as requiring intervention for self
regulation.
26 children who were referred for the program
and consented to participate were randomly
allocated to intervention or control
(no
intervention) group. (22 children participated
fully , one was prescribed medication and
removed from the study and three were lost to
follow up in the control group). Table 1 shows the
time frame for the study.
#
childre
n
Week 1
13
Pre-test
Alert
program
Pre-test
No intervention
Week 9-13
Week 14
Assimilation
The Intervention programs were run by two
occupational therapists and two students.
There were two groups, a children's group (6-9
year olds) and a pre teen group (10- 12 year olds).
Each group was made up of;
•Five weekly 1 ½ hr Sessions with the children.
•Two evening,1½ hr Parent/Teacher information
sessions. Parents were invited and encouraged to
bring staff from schools.
•One 1 ½ hr Follow up session / review with
feedback to parents.
The Alert Program uses the analogy of “how does
your engine run?” to facilitate children in learning
about their levels of alertness and arousal using
the metaphor of engine speeds. For example if
your engine is running in high gear you may feel
angry, overactive or giddy. The program has three
stages; 1) identifying engine speed, 2)
experimenting with methods to change engine
speeds and 3) regulating engine speeds. Each
stage has a series of steps designed to help the
students with self-regulation. The program is run
to incorporate these stages and steps but can be
applied in a variety of ways. (William and
Shellenberger 1996)
Results
The
mean change scores for standardised measures
.
of sensory processing, attention, behaviour and
social skills showed no statistically significant
differences between the control and intervention
group (p>.05), the mean scores on GAS were
significantly higher for the intervention group than
the control group as Table 2 outlines. Figure 1 shows
the spread of the GAS scores for the intervention
group compared to the control group.
Test
P-value
Short Sensory Profile
.378 (ns)
SPM - home
.701 (ns)
SPM - school
.244 (ns)
Leiter – cognitive - home
.577 (ns)
Leiter – emotional – home
.832 (ns)
Leiter – cognitive - home
.496 (ns)
Leiter – emotional - home
.937 (ns)
CBCL total
.165 (ns)
TRF total
.336 (ns)
GAS
.021 (s)
Post-test
Post-test
Parent Feedback and Teacher Feedback
Feedback was gathered through post group survey .
Thematic analysis as outlined in figure 2
demonstrates mainly positive impressions. Parents
and teachers both reported that they found the
strategies and language of the program helpful, but
asked for more information sessions specific to their
individual child's presentation.
Parent View
Recognising
Engine speed
Improved self
image
Tips,
language and
strategies
More follow
up / liaison
Not suited to
specific
problems
Teacher View
More settled
self -aware
attentive
Strategies
and language
Collaborative
working
More follow
up / liaison
/school visits
Figure 2: thematic analysis of the parent and teacher feedback
Conclusion
While the treatment group made no significant gains
on measures of attention, behaviour and social skills
(at home and school) when compared to the control
group, overall there was parent and teacher
satisfaction with the treatment group. Several
factors may have contributed to these results, two of
the most likely being the short length of the
intervention and the lack of sensitivity of the
measures.
The treatment group showed a significant difference
in goal attainment when compared to the control
group. i.e. the treatment group achieved
participation based goals which the control group did
not. (goals independently set with researcher not
clinic OTs). This appears to be related to the specific
and personal nature of the goals.These findings
confirm findings of Mailloux et al. 2007 that “GAS
offers therapists a unique method of capturing
outcomes that are truly meaningful to children and
families”p.258
Limitations of the study include ;
That the researchers / participants were not blind
to allocation and treatment.
 That it was not possible to control for external
variables other than medication and parenting group
e.g. change of school or teacher, diagnosis and
engagement levels.
Recommendations include;
•Further research with larger samples.
•Further investigation of child suitability for alert
program – who decides and how?
•Investigation of factors which influence outcomes,
i.e. length of program, engagement of child, parent
and school, clinic environment.
•Assessment of best practice in terms of size, format
and location of the group.
References
Table 1: time frame for study
Pre and post test measures were used (based on
previous research by Miller et al 2007)
Short Sensory Profile
Sensory Processing Measure (SPM), home and
classroom version
Leiter International Performance Scale–Revised:
Parent Rating Scale and Teacher Rating Scale
(Leiter–R)
The Child Behavior Checklist (CBCL)
Goal Attainment Scaling (GAS)
3
V.
The Program
Table 2: p-values for mean change scores between pre and post measures
(12 male
1 female)
9
(8 male
1
female)
Week 2-8
2
K .,
Figure 1: box plot of intervention and control groups GAS scores
Barnes, K.J., Beck, A.J., Vogel, K.A., Grice, K.O., & Murphy, D. (2003). Perceptions regarding school-based
occupational therapy for children with emotional disturbances.American Journal of Occupational Therapy,
57, 337-341.
Colangelo, C. (2008). Test Drive: Introducing the Alert Program® through song (Reviews,Tidbits and Tools).
Journal of Occupational Therapy, Schools, & Early Intervention, 1:1,70-71.
Dunn, W., & Bennett, D. (2002). Patterns of sensory processing in children with attention deficit hyperactivity
disorder. Occupational Therapy Journal of Research, 22(1), 4-15.
Dunn, W., Myles, B., & Orr, S. (2002). Sensory processing issues associated with Asperger Syndrome: a
preliminary investigation. American Journal of Occupational Therapy, 56, 97-102.
Maas, C., Mason, R., & Candler, C. (2008, Oct. 20). “When I get mad….” An anger management and selfregulation group. OT Practice, 9-14.
Mailloux, Z., May-Benson, T.A., Summers, C.A., Miller, L.J.,Brett-Green, B., Burke, J.P. et al. The Issue Is –
Goal attainment scaling as a meausure of meaningful outcomes for children with sensory integration disorder.
American Journal of Occupational Therapy,61,254-259.
Miller, L.J.,Coll, J.R.& Schoen, S.A.(2007).A Randomized controlled pilot study of the effectiveness of
occupational therapy for children with sensory modulation disorder. American Journal of Occupational
Therapy,61,228-238.
Salls, J. & Bucey, J. (2003, March 10). Self-regulation strategies for middle schoolstudents. OT Practice, 1116.
Williams, M.S. & Shellenberger, S. (1996)."How does your engine run?" A leader's guide to the Alert
Program for self-regulation. Albuquerque, NM: TherapyWorks, Inc
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