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Self-regulation Strategies of Children with Emotional

Disturbance

Article  in  Physical & Occupational Therapy in Pediatrics · February 2008

DOI: 10.1080/01942630802307127 · Source: PubMed

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Self-regulation Strategies of Children withEmotional Disturbance

Karin J. Barnes, PhD, OTRKimberly A. Vogel, EdD, OTR

Alison J. Beck, PhD, OTRHeidi B. Schoenfeld, MA, OTR

Steven V. Owen

ABSTRACT. Children with emotional disturbance frequently have diffi-culty regulating their classroom behaviors. Many have co-occurrence ofother disabilities, such as sensory processing problems, which compounddifficulties in school participation. This exploratory project evaluated the8-week-long use of the Alert Program within the classroom setting forseven children with emotional disturbance. Five children with emotionaldisturbance served as a control group. Self-regulation, behavioral ad-justments, and sensory processing skills as reported by the children and

Karin J. Barnes, PhD, OTR, is Associate Professor, Occupational Therapy, Univer-sity of Texas Health Science Center at San Antonio, San Antonio, Texas.

Kimberly A. Vogel, EdD, OTR, is Associate Professor, Occupational Therapy,University of Texas Health Science Center at San Antonio.

Alison J. Beck, PhD, OTR, is Associate Professor, Occupational Therapy, Univer-sity of Texas Health Science Center at San Antonio.

Heidi B. Schoenfeld, MA, OTR, is Coordinator for Occupational, Physical andMusic Therapy, San Antonio Northside Independent School District, San Antonio,Texas.

Steven V. Owen, is Professor, Epidemiology & Biostatistics, University of TexasHealth Science Center at San Antonio.

Address correspondence to: Karin J. Barnes, Associate Professor, OccupationalTherapy, Mail Code 6245, University of Texas Health Science Center at San Anto-nio, 7703 Floyd Curl Drive, San Antonio, Texas 78229—3900. (E-mail: barnesk@uthscsa.edu).

Physical & Occupational Therapy in Pediatrics, Vol. 28(4), 2008Available online at http://potp.haworthpress.com

C© 2008 by Informa Healthcare USA, Inc. All rights reserved.doi: 10.1080/01942630802307127 369

370 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

teachers were evaluated. Changes from pretest to posttest indicated thatchildren who received the Alert Program demonstrated a small improve-ment on all measures while performance of the control group remainedrelatively constant or decreased. These preliminary results indicate pro-grams that target self-regulation skills may be useful in helping to im-prove self-regulation of children with emotional disturbance.

KEYWORDS. Children, emotional disturbance, self-regulation, schooltasks, occupational therapy

The Surgeon General’s report stated, “One in ten children and adoles-cents suffers from mental illness severe enough to cause some level ofimpairment” (U.S. Public Health Service, 2000, p. 9). According to theTwenty-fourth Annual Report to Congress emotional disturbance is thefourth largest disability group in the public school system, and nearly ahalf million such children were provided special education and relatedservices in the public schools in 2000–2001 (U.S. Department of Edu-cation, 2001). Children with emotional disturbance often have difficultyperforming school occupations involving following directions, complet-ing deskwork, and regulating behaviors at school (Prior, 2001). They mayhave problems in organizational, interpersonal, self-control, coping, andlearning skills.

Emotional disturbance often co-occurs with learning disorders and sen-sory processing problems (U.S. Department of Education, 2000). Studieshave demonstrated that children with emotional disturbance frequentlyshow deficits in processing sensory environmental information (Dunn,2001; Olson, 2001; Prior, 2001). Children with learning disorders andsensory processing problems exhibit difficulties with frustration control,self-regulation, self-control, and academic tasks (Miller, Reisman, McIn-tosh, & Simon, 2001).

Children with emotional disturbance have been underserved by schooloccupational therapists (Beck, Barnes, Vogel, & Grice, 2006). Largecaseloads, emphasis on handwriting, and other staff’s lack of awarenessof occupational therapists’ training in mental health contribute to the ex-clusion of children with emotional disturbance from occupational therapyservices. Some therapists do not feel competent to address the needs ofsuch children (Barnes, Beck, Vogel, Grice, & Murphy, 2003). Additionally,few studies are available indicating that occupational therapy interventionresults in improved educational outcomes for children with emotional dis-turbance.

Barnes et al. 371

The Alert Program (Williams & Shellenberger, 1996) is a systematicintervention designed to help children who have difficulty staying on task orwho become upset due to sound, touch, vision, and movement. The programaims to help children (a) learn to recognize their arousal states within theenvironment as related to behavioral problems, such as their sensitivity andreactions to sounds, touch, and movement in their surroundings and (b)expand their self-regulation strategies used in various school occupations.The Alert Program uses cognitive learning and sensory activities to helpchildren become aware of, maintain, or change their levels of alertnessto match the demands of a situation or task (Williams & Shellenberger,1996). In a school setting, self-regulation of alertness translates to readinessto learn and participation in school occupations. For example, if a childhas difficulty staying on task, the child could use an oral strategy, suchas chewing on a straw, to help stay focused. As another example, if theentire class was having difficulty quieting down following a transition,the teacher could have all the children “push on the wall” as a means toprovide proprioceptive input to help regulate their arousal levels (Williams& Shellenberger, 1996).

Grove (2002) suggested that the Alert Program could be adapted to helpchildren understand their emotional states and maintain self-control in dif-ferent situations. She credited the Alert Program as an easily implementedapproach to address children’s psychosocial needs. Salls and Bucey (2003)used the Alert Program in a middle school special education, collabora-tive classroom-based curriculum to help the children self-regulate theirbehavior and improve communication skills. Children showed progress inself-awareness, problem solving, and self-regulation strategies, althoughresults were not analyzed statistically. Additionally, teachers, principals,speech therapists, and occupational therapists found it to be cost-effectiveand a model for best practice in a school setting (Salls & Bucey, 2003, p. 15).Schoonover (2002) used the Alert Program with kindergartners, first andsecond graders to teach social skills. All children had problems with socialawareness, peer relationships, self-regulation, and expressive language,which interfered in their student and friend occupations. Although resultswere not analyzed statistically, after a year of intervention, group leadersconcurred that all the children showed improvements in social skills.

Although the Alert Program was reported as one of the most frequentlyused interventions by occupational therapists providing services to childrenwith emotional disturbance, research evidence is lacking (Barnes et al.,2003). Barnes, Schoenfeld, Garza, Johnson, and Tobias (2005) conducteda small preliminary study using the Alert Program with three boys, ages 10–11 years old, with emotional disturbance and sensory processing problems

372 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

using a multiple baseline time series design. The program was providedin a self-contained classroom for children with emotional disturbance in apublic school. Data were analyzed using trend line analysis; no inferentialstatistical analysis was used. Results were inconclusive but children showedtrends in improvement of social behaviors and self-concept, and a decreasein classroom negative behaviors.

The purpose of the present study was to evaluate the Alert Program(Williams & Shellenberger, 1996) for children with emotional disturbancein classroom settings. The following research question was addressed:to what extent does use of the Alert Program result in improvement in(1) sensory processing, (2) self-regulation, and (3) behavioral adjustmentskills of children with emotional disturbance as reported by the childrenand teachers?

METHOD

Design

This study used a quasi-experimental pretest/posttest design with acontrol group, and was conducted in the classrooms of the partici-pants. This design was selected due to the limitation of small num-bers in each classroom. The study examined the effectiveness of theAlert Program on the behaviors of the children in two classrooms,compared to the corresponding behaviors of children in two controlclassrooms who received the standard educational programs. Becausethis study was conducted in the students’ natural environment us-ing existing classes for children with emotional disturbance, random-ized group assignment nor alteration of the classroom makeup was notpossible.

Participants

The 12 participants were children, ages 9 to 11 years old, in four class-rooms for children with emotional disturbance in a public school. Becausethis study was conducted in the children’s classrooms, child characteristicswere not specified a priori. Each classroom had three to four children. Allchildren had the special education classification of emotional disturbanceas determined by the school psychologist based on criteria as specified inIDEA (IDEA, 2004). “For eligibility purposes, IDEA 04 defines emotionaldisturbance (ED) as it relates to learning, the educational environment, and

Barnes et al. 373

behavior not conducive to learning” (Chander, 2007). Each child tookbetween 1–5 medications for his or her emotional disturbance. Intelli-gence Quotient (IQ) was measured by the school psychologist, using avariety of valid standardized measurement tools. Eleven children had IQscores between 77 and 123 and one child had a score of 57 (mild men-tal retardation). In the intervention group, there were 5 boys and 2 girls;5 were white, 1 black, and 1 Hispanic. In the control group, there were5 boys: 3 white, 1 black, and 1 Hispanic. The study was approved bythe Institutional Review Board of The University of Texas Health Sci-ence Center at San Antonio and the public school district’s external re-search board. Informed consent of parents and assent of children wereobtained.

Measures

Sensory Profile

In this study, teachers completed the Sensory Profile on each child.The Sensory Profile (Dunn, 1999) is a standardized measure of sensoryprocessing abilities of children, ages 5–10 years old designed to profile ef-fects of sensory processing on functional performance of daily living tasks.The Sensory Profile consists of 125 items and three main sections: Sen-sory Processing, Modulation, and Behavioral, and Emotional Responses.Scores are interpreted as follows: a “Typical Performance” score is one thatis at or above −1 Standard Deviation (SD) below the mean; a “ProbableDifference” score is one that is at or above the −2 SD but below −1 SDfrom the mean; and a “Definite Difference” score is below −2 SD fromthe mean (Dunn, 1999).

Devereux Behavior Rating Scale (DBRS) (BRS)-School Form

The Devereux Behavior Rating Scale (DBRS) (BRS)-School Form(Naglieri, LeBuffe & Pfeiffer, 1993) is a standardized measure of interper-sonal problems, inappropriate behaviors/feelings, depression, and physicalsymptoms/fears for children (5–18 years). The DBRS evaluates behaviorsthat are typical of children with moderate to severe emotional disturbance.Behavior ratings are interpreted as standard scores with significance levelsreported. In this study, the children’s teachers completed the Devereux.

374 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

Measures of Self-Efficacy for Self-Regulation

Self-efficacy for self-regulation was measured by two tools: childself-report and teacher report. The Self-Efficacy for Self-Regulation ofSchool-aged Children and Teacher’s Perception of Student’s Efficacyin Self-Regulation instruments were developed for this study. The self-regulation items concern the children’s abilities to regulate their behaviorswithin the environment. The aim is for the child and teacher to look at howeffective the child is at self-regulation. The format of the instruments usesself-efficacy questions such as “How good are you at calming yourselfdown after something bothers you?” The support for this format comesfrom Bandura’s (1989) research on self-efficacy. Bandura (1989) empha-sized the importance of “self-efficacy beliefs. . . as determinants of humanmotivation, affect, and action” (p. 1175) and proposed self-efficacy as auseful way to measure behavioral change. Owen and Froman (2007) indi-cated, “Research in a variety of fields has repeatedly shown the importanceof self-efficacy in influencing motivation, self-regulated behavior, affect,and accomplishment” (p. 3). “Self efficacy refers to a belief that one canaccomplish some behavior” (Owen & Froman, 2007, p. 1) and is frequentlymeasured by statements of how well the person believes he or she is ableto do something (Schwarzer, 1998).

Before these instruments were used in this study, 12 occupational thera-pists, who work with children with emotional disturbance, rated each of theitems for relevance and importance. For content validity evidence, intra-class correlation coefficients (ICC) were calculated to examine the experts’congruence about the perceived relevance and importance of various items.The ICC for relevance was .75 and the ICC for importance was .80. Themagnitude of the coefficients suggested that the experts had general agree-ment about the relevance and importance of the items. Additionally, itemusability was assessed by asking four children (not in the study) if theyunderstood each question, and, if not, how to say it better. The childrenmade suggestions about word changes. For example, one boy suggestedthat the word “sluggish” be changed to “sleepy.” Their suggestions wereincorporated into the final wording to improve clarity. Inter-rater agree-ment was evaluated by scoring seven children not included in the study.Percent agreement across three scorers was 98.7.

A checklist, Self-Efficacy for Self-Regulation of School-aged Children,was designed to ask the child to describe his or her perception of howwell he or she is able to regulate behaviors in the classroom, playground,during work tasks and during transition from task to task. This instrumentconsists of 31 behaviors organized under the categories: (1) monitoring

Barnes et al. 375

self, (2) organizing self, (3) maintaining a task, (4) completing a task, (5)adjusting to changing conditions, (6) coping with sensory environmentalchallenges, (7) having control after being upset, (8) getting help fromadults, and (9) getting along with others. A scale of 1 to 5 is used (1 = verypoor, 5 = very good). Mean scores are used to interpret each behavior. Thechildren answered the questions for this checklist.

A checklist, Teacher’s Perception of Student’s Efficacy in Self-Regulation, was developed in which the teacher reports a child’s ability toself-regulate, using the same 31 items, and the same 5-point response scaleas in the child’s self-report version.

Procedures

The first four authors implemented the study. Two authors providedthe intervention and two authors administered the pretest and posttestmeasures. The authors who were in the control classroom were thosethat conducted the testing. Prior to the start of the study, the teachers ofchildren in the intervention group attended a training session given by theresearchers. They were provided an overview of sensory processing andits importance in everyday life, along with training in the Alert Program.

Pretest measures were administered within 2 weeks prior to the startof the intervention phase. The intervention phase lasted 8 weeks. The twoclassrooms attended by children in the intervention group received the AlertProgram intervention from one researcher each. The number of weeklysessions started with three for weeks 1–3 and decreased by one sessionevery 2 weeks. The two researchers conducting the intervention followedthe steps and procedures as described in the Alert Program manual, with thechildren for the duration of the study, with the assistance of the teacher andclassroom assistant. The teachers incorporated the Alert Program strategiesinto the ongoing classroom activities.

During the 8 weeks the Alert program was provided, a researcher at-tended each of the two classrooms of children in the control group duringclass times and assisted the teacher with the routine classroom activities.Therefore, there was a researcher in each of the control group classroomsfor the same amount of time as in the intervention group classrooms.

The two researchers providing the intervention met regularly throughoutthe 8 weeks to ensure that they were using the same procedures as specifiedin the Alert Program manual thereby standardizing the intervention. Thesame sequence and general activities as specified in the manual were usedin the classrooms. Some variation was allowed for individual children,

376 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

such as participation in book fairs and fieldtrips, but this did not alter thesequence or type of intervention. At the end of the 8 weeks, the posttestmeasures were administered.

Data Analysis

In this exploratory study, the very small sample creates poor statis-tical power, making it difficult to detect treatment effects. Although pvalues were reported, descriptive summaries and effect sizes were empha-sized, which are independent of sample size (Vaughan, 2007). The pretest–posttest results from the Sensory Profile were analyzed using comparisonof the mean group pretest scores to the mean group posttest scores.

The participants’ standard scores on the Devereux Behavior Rating Scalewere analyzed to determine if there were significant differences betweenthe pretest and the posttest standard scores, using the significance level ofp = .10 (90%). The probability level was determined by comparing therange of scores of the posttest that could have occurred due to measurementerror and regression effects. When a posttest score was outside of this range,then it may be concluded that the posttest score represented a significantchange in behavior (Naglieri et al., 1993). Significance of change wasobtained by using the Posttest Confidence Ranges for Pretest–PosttestStandard Score Comparisons table in the DBRS manual (Naglieri et al.).

The participants’ scores on the two checklists, Self-Efficacy for Self-Regulation of School-aged Children and the Teacher’s Perception of Stu-dent’s Efficacy in Self-Regulation, were analyzed to determine if there weredifferences between the pretest and the posttest scores. The central statisti-cal procedure was a 2 (group) × 2(occasion) repeated measures ANOVA.Such an ANOVA model produces three significance tests, but the main ef-fects are typically ignored in favor of the interaction term. The interactionquestion asks whether the two groups changed differently over time.

RESULTS

Sensory Profile

Pretest results of the Sensory Profile indicated that all 12 children hadsome sensory processing difficulties in the Sensory Processing, Modula-tion, and or Behavior & Emotional Responses Sections.

Barnes et al. 377

TABLE 1. Sensory Profile Section Summary: Intervention Group TeachersResponses—Mean Scores [X = mean score]

Intervention group [n = 7]

Pretest—Means Posttest—Means

Typical Probable Definite Typical Probable DefiniteFactors Performance Difference Difference Performance Difference Difference

Sensory processingA. Auditory

processingX X

B. Visualprocessing

X X

C. Vestibularprocessing

X X

D. Touchprocessing

X X

E. Multisensoryprocessing

X X

F. Oral sensoryprocessing

X X

ModulationG. Sensory

processingrelated to en-durance/tone

X X

H. Modulationrelated tobody position& movement

X X

I. Modulation ofmovementaffectingactivity level

X X

J. Modulation ofsensory inputaffectingemotionalresponses

X X

K. Modulation ofvisual inputaffectingemotionalresponses &activity level

X X

(Continued on next page)

378 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

TABLE 1. Sensory Profile Section Summary: Intervention Group TeachersResponses—Mean Scores [X = mean score](Continued)

Intervention group [n = 7]

Pretest—Means Posttest—Means

Typical Probable Definite Typical Probable DefiniteFactors Performance Difference Difference Performance Difference Difference

Behavior &EmotionalResponses

L. Emo-tional/Socialresponses

X X

M. Behavioraloutcomes ofsensoryprocessing

X X

N. Itemsindicatingthresholds forresponse

X X

Summary meanscore totals

11 3 0 12 2

Intervention Group

The mean Sensory Profile scores for the seven children in the inter-vention group indicated little change between pretest and posttest scores(Table 1). Mean scores that improved from Probable Difference to TypicalPerformance were for the specific factors of Auditory Processing, Behav-ioral Outcomes of Sensory Processing and the Items Indicating Thresholdsfor Response. In the specific factor of Multisensory Processing, the posttestscore changed from Typical Performance to Probable Difference.

Control Group

The mean Sensory Profile scores for the five children in the control groupindicated a decrease between pretest and posttest from Typical Performanceto Probable Difference for the factors of Multisensory Processing, Oral

Barnes et al. 379

TABLE 2. Sensory Profile: Control Group Teachers Responses—MeanScores [X = total means]

Control group [n = 5]

Pretest—Means Posttest—Means

Typical Probable Definite Typical Probable DefiniteFactors Performance Difference Difference Performance Difference Difference

Sensory processingA. Auditory

processingX X

B. Visualprocessing

X X

C. Vestibularprocessing

X X

D. Touchprocessing

X X

E. Multisensoryprocessing

X X

F. Oral sensoryprocessing

X X

ModulationG. Sensory

processingrelated to en-durance/tone

X X

H. Modulationrelated tobody position& movement

X X

I. Modulation ofmovementaffectingactivity level

X X

J. Modulation ofsensory inputaffectingemotionalresponses

X X

K. Modulation ofvisual inputaffectingemotionalresponses &activity level

X X

( Continued on next page)

380 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

TABLE 2. Sensory Profile: Control Group Teachers Responses—MeanScores [X = total means](Continued)

Behavior &emotionalresponses

L. Emotional/socialresponses

X X

M. Behavioraloutcomes ofsensoryprocessing

X X

N. Itemsindicatingthresholds forresponse

X X

Summary meanscore totals

9 2 3 5 6 3

Sensory Processing, Sensory Processing Related to Endurance/Tone, andModulation of Sensory Input Affecting Emotional Responses (Table 2).

Devereux Behavior Rating Scale (DBRS)

The results for the DBRS indicated that both groups’ pretest scores weresimilarly spread from normal to very significant problems. Six children inthe intervention group demonstrated improvement in the posttest standardscore and one child showed a decrease (Table 3). Of those showing animprovement, two were significant changes (p = .10) and for the subjectwith a decreased standard score, the change was significant (p = .10). Allof the children in the control group showed decreases on posttest standardscore and of these, four were significant decreases (p = .10).

Self-Efficacy for Self-regulation and Teacher Perceptions of Student’sEfficacy in Self-regulation

Table 4 includes the percent change of each child on each measure.There were differences between child self-appraisal and teacher appraisal.In 9 out of 12 children, the child self-ratings were higher than those of

Barnes et al. 381

TABLE 3. Change from Pretest to Posttest Scores on Devereux BehaviorRating Scale

Subjects Standard score change

Intervention group1 improved2 improved∗3 improved4 improved9 improved∗

10 improved11 decreased∗

Control group5 decreased∗6 decreased∗7 decreased∗8 decreased

13 decreased∗

∗p = .10

their teacher. The discrepancies between child and teacher ratings werevery wide for the children in the control group, at both pretest and posttest.

Table 5 summarizes the ANOVA for child self-reported self-regulationof self-efficacy. No effect was statistically significant, although the Groupmain effect showed an effect (η2 = .18) medium in size, according to Co-hen’s (1988) guidelines. The interpretation of the Group effect is that thechildren in the control group average pre/post scores were higher than thoseof the children in the intervention group. Control group average pre/postscores were higher than those of the children in the intervention group.Note, however, that calculating the average of pre and post scores saysnothing about change over time, and the Group effect may simply be an ar-tifact of non-random group membership. That is, by chance alone, studentsin the control condition began with substantially higher self-efficacy scores,which gave them an advantage in the overall Group effect (see Table 5).

Table 6 summarizes the ANOVA for teacher ratings of child efficacy inself-regulation. The Group effect was significant (p = .04), with a largeeffect size. Examination of the group means shows that the teachers ratedthe children in the control group substantially lower at both pretest andposttest. Neither within-groups effect—Occasion or Group × Occasion—were significant, but the interaction term nonetheless showed a large effect(η2 = .25). Inspection of the cell means shows that teacher ratings improved

382 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

TABLE 4. Pretest to Posttest Percent Change for “Self-Efficacy forSelf-Regulation of School-Aged Children” and “Teachers Perception ofStudent’s Efficacy in Self-Regulation”

Subjects Children’s perceptions Teachers’ perceptions

Intervention Group Individuals’ Percent Change1 −3% −12%2 +46% +32%3 +10% +21%4 +44% +21%9 −13% +22%

10 −7% +7%11 −3% −16%

Control Group Individuals’ Percent Change5 −1% −9%6 +8% −7%7 +2% −4%8 −4% −8%

13 −1% −29%

over time for the children in the intervention group (pre = 3.2; post = 3.5),but declined for the children in the control group (2.5 to 2.2).*

DISCUSSION

Sensory Profile

All of the children presented with some sensory processing abilities out-side of the Typical Performance range. Teachers reported an improvementtoward Typical Performance in posttest scores for the children in the in-

TABLE 5. Analysis of Variance Source Table for Child-ReportedSelf-Regulation Self-Efficacy

Source SS df MS F p Eta squared

Group 3.68 1 3.68 2.24 .17 .18Error between 16.48 10 1.65Occasion < .01 1 < .01 .01 .91 < .01Group × Occasion. < .01 1 < .01 < .01 .99 < .01Error within .69 10 .07

Barnes et al. 383

TABLE 6. Analysis of Variance Source Table for Teacher-ReportedSelf-Regulation Self-Efficacy

Source SS df MS F p Eta squared

Group 5.74 1 5.74 5.37 .04 .36Error between 10.69 10 1.07Occasion .01 1 .01 .05 .83 .01Group × Occasion .45 1 .45 3.37 .10 .25Error within 1.34 10 .13

tervention group, whereas the posttest scores of the children in the controlgroup remained the same or moved away from the Typical Performancecompared to their pretest scores. This implies that the Alert Program mayhave helped the children in the intervention group in their adaptation tothe classroom sensory environmental contexts. The reason why the controlgroup scores decreased is unknown. The results of this study suggest theAlert Program may have contributed to improved sensory processing skillsin the classroom, as measured by the Sensory Profile, in children withemotional disturbance. The small sample size and the length of the study,however, are causes for caution in regards to possible changes in sensoryprocessing.

Devereux Behavior Rating Scale-School Form (DBRS)

While children in the intervention and control groups had similar rangesof pretest scores from normal to very significant problems on the DBRS,the intervention group’s posttest scores showed improvement in behavioralskills. This suggests that the Alert Program experience may have helped thechildren in the intervention group improve in the behavioral areas tested bythe DBRS, specifically in their interpersonal skills, appropriate behaviorand feelings, depression, and physical symptoms/fears, as observed by theteachers. We surmise that the classroom-based Alert Program interventionhas helped the children learn and use strategies of self-regulation of thosebehaviors targeted by the DBRS.

Self-Efficacy for Self-Regulation of School-Aged Children

Within group scores (Table 4) of the intervention group varied widelyafter children participated in the Alert Program. This may indicate that

384 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

some children became more effective at self-monitoring and self-regulatingtheir behavior, thus rating themselves higher in the posttest. For example,a child in the intervention group stated, “Liked activities. Sit on red thing.Have to ask my teacher to use them. Learned to use them when you getexcited or hyper.” Others may have gained realization that they need toself-regulate, but felt they were not effective in doing so, and so ratedthemselves lower. With additional time and practice, perhaps the childrenwould improve their ability to self-regulate and perceive success, leadingthem to report higher scores on the self-rating form. The control groupscores showed little change and little variation.

Teacher’s Perception of Student’s Efficacy in Self-regulation

Results for the Teacher’s Perception of Student’s Efficacy in Self-regulation indicate that teachers’ perceived that children in the interven-tion group showed an improvement in self-regulation ability while chil-dren in the control group’s ability to self-regulate behavior decreased.Results suggested the Alert Program was effective in helping to improv-ing children’s abilities to self-regulate, change tasks, organize themselves,cope with sensory challenges, and focus on tasks in the classroom asperceived by teachers. However, it must be noted that the teachers ofthe children in the intervention group received initial training and par-ticipated in the Alert Program interventions, which may have causedbias.

The findings suggest that children with emotional disturbance may beunaware of their difficulties with self-regulation or how their behavior isperceived by others. Nine out of twelve children rated themselves consid-erably higher than teachers rated them on pretest and posttest measures.A curious finding was the contrast between Child 9’s posttest self rating,which was much lower than her pretest rating, and the teacher’s posttestrating, which was much higher than Child 9’s posttest rating. The teacherstated that Child 9 had developed more effective self-regulation, in contrastto Child 9’s apparent feelings about her own abilities.

While this study was limited in size and by small changes across thepretest and posttest measures, the results suggest that self-regulationand sensory processing interventions, such as the Alert Program, thattarget classroom occupations can be viable classroom interventions usedby occupational therapists and teachers. Because the Alert Programwas conducted in the classroom the teachers were able to learn as thechildren learned. With this in-class interaction, the teachers exhibited

Barnes et al. 385

enthusiastic cooperation and willingness to carry out the program.Together the occupational therapists and the teachers could customizethe activities to the individual classrooms. The Alert Program strategieswere used throughout the day, thus increasing the amount of practice andgeneralization for the children.

The fact that the intervention occurred in the classroom and involvedthe teachers’ helped them to become more perceptive of children’s sen-sory processing problems and to the classroom sensory environments. Theteachers told the occupational therapists that between intervention sessionsthey recognized the need for the children to use Alert Program strategiesand encouraged them to do so. This increased awareness may have helpedthe teachers anticipate environmental sensory triggers so consequentialnegative reactions could be avoided. A classroom intervention could al-low teachers to use group influence to help individual children when theyhave behavioral difficulties related to the sensory environment. For exam-ple, if a child is having difficulty regulating her behavior during a groupassignment, a teacher can stop and request that the entire class engagesin a 60-s self-regulatory activity. This allows them to all work togetherand model for each other ways to obtain the appropriate arousal level forthe assignment. Thus, an individual child is neither singled out nor stig-matized. Attention to each child’s self-regulation behaviors is especiallyimportant in classrooms for child with emotional disturbance because onechild’s negative behavioral escalation can have a contagion effect on otherchildren’s behaviors.

This study has limitations that restrict generalization. A small samplefrom one school in a specific geographic location was used. The classroomenvironments were more highly structured than regular education class-rooms, so generalization to other types of classrooms is limited. Also, theapparent co-occurrence of emotional disturbance with sensory processingproblems with these children does not imply that co-occurrence with otherdisorders is an automatic finding for children with emotional disturbance.The researchers did not control for the family environment, which, es-pecially in this population, may affect the children’s performance. Thechildren had differing medication profiles for their emotional disorders,which can influence performance skills and client factors. The researcherswere unable to monitor the medication regimen and dosage. Lastly, whilethere were improvements in the intervention group scores over that ofthe control group, the changes were small and represent preliminary data.More clinical research and increased classroom use is needed to confirmthe value of the Alert Program in strengthening classroom self-regulationsskills.

386 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

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Barnes, K., Schoenfeld, H., Garza, L., Johnson, D. & Tobias, L. (2005). Preliminary:Alert Program for boys with emotional disturbances. School System Special InterestSection Quarterly, 12(5), 1–4. American Occupational Therapy Association.

Beck, A., Barnes, K., Vogel, K. & Grice, K. (2006). The dilemma of psychosocialoccupational therapy in public schools: The therapists’ perceptions. OccupationalTherapy in Mental Health, 22(1), 1–17.

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