The Alert Program for Self Regulation an evaluation

The Alert Program for Self Regulation an evaluation of a group based intervention for children attending a child and adolescent mental health service (CAMHS) ® 1 K. , Cremin Lamb O’Connell 1 Discipline of Occupational Therapy, Trinity College Dublin, 2. Lucena Clinic, Rathgar 3. Mater Child and Adolescent Mental Health Service. 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 otherapies. 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 (12 male 1 female) Week 2 -8 Week 9 -13 Week 14 2 K. , The Program 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) Table 2: p-values for mean change scores between pre and post measures 9 Pre-test (8 male 1 female) Alert program Assimilation No intervention 3 V. Post-test Parent Feedback and Teacher 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. Post-test 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) 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: Therapy. Works, Inc

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