Using Occupational Performance Coaching to target teachers’ perception of their

own performance, satisfaction, and self-efficacy in supporting the self-regulation of their students: A pilot study

Caroline Hui School of Physical and Occupational Therapy

Faculty of Medicine, McGill University, Montreal, Quebec December, 2013

A thesis submitted to McGill University in partial fulfillment of the requirements of the degree of Master’s of Science.

©Caroline Hui, 2013

Abstract

The policy of inclusive education has changed the makeup of the Canadian classroom.

Today’s elementary school teacher is faced with the challenge of meeting the myriad classroom

needs of their students, many of whom demonstrate disruptive classroom behaviours due to

different underlying diagnoses. It is known that these behaviours have a large impact on a

teachers’ stress level. This increased stress can lead to reduced performance, dissatisfaction in

performance, and lower self-efficacy. Only 13% of surveyed Canadian teachers felt they could

manage the challenge of these behaviours. Preliminary studies of the Alert Program®, an

innovative program which promotes the use of sensorimotor strategies to enable students to

attain and maintain an appropriate level of arousal and self-regulation for learning, have shown

effectiveness. Occupational Performance Coaching (OPC), an occupation and client centred

approach, has been shown to be successful in helping adults meet their occupational goals.

The primary objective of this master’s thesis was to estimate the extent to which elementary

school teachers’ perceived performance, satisfaction of performance, and self-efficacy changed

following participation in a one day training and weekly OPC on the use of tools for self-

regulation of their students. This study used a multiple case replication study design. A cohort

of regular classroom elementary school teachers (n=11) were recruited from the Quebec

Eastern Townships School Board. Intervention took place over a period of 11.3 weeks. The

intervention included a one day workshop, based on the Alert Program®, entitled Tools to

Improve Attention and Self-regulation for Students in the Classroom and was followed by eight

individual sessions of OPC with the teachers. The key outcome measures were the Canadian

Occupational Performance Measure (COPM), used to assess the teachers’ perceived

i

performance and satisfaction performance in supporting self-regulation of their students, and

Goal Attainment Scaling (GAS) to evaluate functional goal attainment. The Teachers’ Self-

Efficacy Scale-Classroom Management (TSES-CM) was used to measure teacher’s self-efficacy in

classroom behaviour management. Open ended questions were used in semi-structured

interviews and a daily log was filled out by the teachers to collect data on the sensorimotor

strategies implemented in their classroom.

The results of this pilot study suggest that the use of a workshop and OPC sessions with

teachers improved their perceived perception, satisfaction and self-efficacy when working with

students with self-regulation issues. Perceived performance improved in 82% of participants,

perceived satisfaction improved in 91% and self-efficacy improved in 73% of participants.

Overall results on outcome measures indicated clinically significant change with a probability of

response at 0.77 (CI=0.58, 0.85). The results of GAS indicate that progress was noted in

teachers as well as students. Preliminary results suggest that the use of OPC as a school-based

OT intervention with teachers can be beneficial.

ii

Résumé

La politique de l’éducation inclusive a modifié le portrait de la salle de classe canadienne.

Aujourd’hui, les enseignants au niveau du primaire font face au défi de répondre aux

innombrables besoins de leurs étudiants dans la classe, plusieurs de ces derniers adoptant un

comportement inadéquat en raison de troubles sous-jacents. On sait que ces comportements

ont un important impact sur le niveau de stress des enseignants. Ce stress accru peut entrainer

une diminution de la performance, un mécontentement quant au rendement occupationnel et

une plus faible auto-efficacité. Seulement 13 % des enseignants canadiens sondés sentent être

en mesure de gérer les comportements perturbateurs dans la classe. Les études préliminaires

sur le « Alert Program® », un programme innovateur qui enseigne comment utiliser des

stratégies sensorimotrices pour atteindre et conserver le niveau adéquat d’éveil pour

l’apprentissage chez les étudiants, a démontré son efficacité à permettre aux enseignants de

soutenir leurs étudiants dans leur autorégulation. « Occupational Performance Coaching »

(OPC), une approche centrée sur le client et l’occupation, a démontré du succès avec les adultes

afin de réaliser leurs buts.

L’objectif général de cette thèse était de estimer jusqu’à quel point la perception du

rendement des professeurs, leur satisfaction quant à leur rendement et leur auto-efficacité ont

changées à la suite de leur participation à une formation d’une journée suivie de sessions

régulières de OPC visant à les aider à soutenir l’autorégulation de leurs étudiants. La devise de

l’étude était une étude de cas multiple avec réplication. Des enseignants (n=11) au niveau du

primaire ont été recrutés à la Commission scolaire Eastern Township, au Québec et

l’intervention s’est déroulée sur une période de 11,3 semaines. Elle prévoyait une journée

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d’atelier, basé sur le « Alert Program® », intitulé Outils pour améliorer l’attention et

l’autorégulation des étudiants dans la salle de classe. L’atelier était suivi par huit sessions

individuelles de l’OPC avec les enseignants. Les outils d’évaluations utilisées étaient la Mesure

canadienne du rendement occupationnel (MCRO) pour évaluer comment les enseignants du

primaire perçoivent leur rendement et leur satisfaction quant à leur rendement lorsqu’ils

soutiennent l’autorégulation de leurs étudiants. Le « Goal Attainment Scale » (GAS) a aussi été

utilisé. Le « Teachers' Self-Efficacy Scale - Classroom Management » (TSES-CM) a été utilisé

pour mesurer l’auto-efficacité des professeurs dans la gestion du comportement en classe. Des

questions ouvertes ont été utilisées lors d’entrevues semi-structurées et les enseignants on

remplit un journal quotidiennement afin de recueillir des renseignements sur les stratégies

sensorimotrices mises en œuvre dans la salle de classe.

Les résultats de cette étude pilot suggèrent que l’utilisation de l’OPC avec des enseignantes a

amélioré leur perception de leur participation et satisfaction ainsi que l’auto-efficacité pour

travailler avec des élèves qui ont des difficultés d’auto-régulation. La perception de

performance c’est amélioré dans 82% des participants, la satisfaction c’est amélioré pour 91%

des participants, et l’auto-efficacité c’est amélioré pour 73% de participant. Les résultats

globaux dans les tests MCRO, GAS et TSES-CM indiquent des changements significatifs, avec

une probabilité de réponse de 0,77 (Intervalle de confiance=0,58, 0,85). Les résultats du GAS

indiquent que du progrès a été mesuré au niveau des enseignants ainsi qu’au niveau des élèves.

Des résultats préliminaires suggèrent que l’OPC est une intervention ergothérapique bénéfique

qui pourrait être utilisé dans les écoles.

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Contribution of Authors

Caroline Hui BSc OT I, the candidate, am the author of this thesis. I performed the literature review, recruited

participants, collected the pre-intervention measures, provided the intervention, and collected the post-intervention and follow-up measures. I completed the data interpretation and discussion. Laurie Snider PhD

Dr. Snider provided guidance throughout the study. She reviewed the thesis and provided expertise on methodology, measurement outcomes, content and structure. Ingrid Sladeczek PhD

Dr. Sladeczek reviewed the thesis and provided expertise on content and structure as well as guidance for statistical interpretation.

Mélanie M. Couture PhD

Dr. Couture reviewed the thesis and provided expertise on content and structure. She also provided numerous helpful insights regarding methodology.

v

Statement of Authorship

I certify that I am the primary author of this thesis. I claim full responsibility for content and style of the text included herein.

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Acknowledgements

Returning to school after more than twenty years of clinical work has been a challenge that I

could not have done by myself. It has been a journey, one of discovery and sometimes pain, but

definitely a journey of growth. Although I spent many hours in isolation with my laptop and

piles of papers working on this degree, I was not alone. I felt supported in many ways.

Dr. Laurie Snider, my supervisor, provided encouraging words and valuable insight

throughout this process. She always knew what to say to keep me going and her attention to

detail was a great contribution to the evolution of this thesis. Her dedication to pediatric

research is inspiring. I would also like to thank Dr. Fiona Graham for her never ending support

with Occupational Performance Coaching. Regardless of the New Zealand and Quebec time

differences, she was always there when I needed.

I would also like to extend my gratitude to my supervisory committee Dr. Mélanie M.

Couture from Université de Sherbrooke and Dr. Ingrid Sladeczek from McGill University. Their

advice and research experience were always helpful. In addition, thank you to Dr. Nancy Mayo

and Dr. Susan Scott from McGill University for their patience with my questions on statistics.

Their help was valuable.

I appreciated the financial support of the Richard and Edith Strauss Foundation of Canada

and the Judith Kornbluth Gelfand Pediatric Fellowship. Their financial support was very much

appreciated.

It is the teachers who participated in this study who made it happen. Without them, I’d still

be waiting and recruiting. Thank you. Thank you for opening up your classrooms to me and for

sharing your hardships and successes. Your dedication to your profession and to your students

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is an inspiration to me. ETSB is privileged to have you and I was privileged to get the

opportunity to work with you. Thank you.

Finally, I want to thank my friends and family. Sophie and Lyette, thank you for answering

my phone calls and encouraging me every time. They believed in me. Of course, without the

support of my husband, Louis and my children, Amélia and Tristan, I would never have begun

this personal project. Thank you to my mother for her belief that I can do anything I set my

mind to doing. And to Pop, my guardian angel, I cannot thank you enough.

You all have been supportive and encouraging throughout this process. I truly appreciate

your patience and thank you for helping me realize my dream! I dedicate this thesis to my

children. There is nothing that you cannot do if you really want: follow your dreams.

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Table of Contents

ABSTRACT………………………………………………………………………………………………….………… i RESUMÉ……………………………………………………………………………………………………………….. iii CONTRIBUTION OF AUTHORS………………………………………………………………………………. v STATEMENT OF AUTHORSHIP………………………………………………………………………………. vi ACKNOWLEDGEMENTS……………………………………………………………………………..…………. vii TABLE OF CONTENTS…………………………………………………………..……………………………….. ix LIST OF FIGURES…………………………………………………………………..………………………………. xi LIST OF TABLES………………………………………………………………………………………….…………. xii LIST OF APPENDICES…………………………………………………………….………………………………. xiii LIST OF ABBREVIATIONS…………………………………………………………………………….………… xiv GLOSSARY OF TERMS…………………………………………………………….……………………………. xv PREFACE……………………………………………………………………………………………..…….…………. xvii 1. GENERAL INTRODUCTION……………………………………………………………………..…………. 1 2. BACKGROUND……………………………………………………………..……………..……………………5

Heterogeneity of students in regular classrooms………………………….. …………. 5 Identifying the problem…………………………………………………………………………….. 7

Teacher workload………………………………………………………………….…………………. 7 Teacher stress……………..……………………………………..……………………..…………… 8 Self-efficacy of teachers……………………..…………………………….…..…………………. 10

Solution/Action Process…………………………………………………………………………….. 10 Occupational therapy …………………………………..…….……………………………………. 11 Collaboration between occupational therapists and teachers………..………… 12 Occupational Performance Coaching …………………….….…………………..………… 14 Sensory processing…………………………………………………………………………………… 18 Impact of sensory processing on student behaviour…………………………………. 20

Sensory processing impacts self-regulation………………………………………………. 23 Self-regulation and demands on the teacher………………………………………….. 25

The Alert Program®………………………………………...……………………………………….. 25 Sensorimotor strategies: Five methods of the Alert Program®……………….. 29 (1) Put something in your mouth…………………………………..………….…………. 30 (2) Move …………………………………..…….………………………………………..………… 32 (3) Listen…………………………………..…….…………………………………………………… 35 (4) Look…………………………………..…….…………………………………………..………… 36 (5) Touch…………………………………..…….………………………………………..…………. 36 Knowledge Translation…………………………………………………………………………… 39 Rationale………………………………………………………………………………………………….. 42 3. OBJECTIVES………………………………………………………………………………………………………. 44 4. METHODS……………………………………………………………………………..……………….………… 45

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Monitoring knowledge use……………………………………………………………………….. 45 Participants……………………………………………………………….…….……….………………. 45 Design………………………………………………………………………………………......…………. 45

Outcome measures………………………………………………………………………………….. 46 Canadian Occupational Performance Measure………….…………………………. 46 Goal Attainment Scaling ……………………….……………………........................... 47 Teacher Self-Efficacy Scale: Classroom Management subscale…………….. 49

Process of implementation measures………………………………………………………. 50 Child Behavior Checklist for ages 6-18: Teacher’s Report Form……………. 50 Semi-structured interview………………………………….………………………………… 51 Fidelity Measures…………………………………………………………………………………. 51

Procedures……………………………………………………….….………………………………..…. 52 Analysis……………………………………………………………………………………………………. 55 Confidentiality…………………………………………………………...……………………………. 56 Ethical Considerations…………………………………………………...…………………………. 56

5. RESULTS………………………………………………………………………………..……………….………… 58 Outcome measures……………………………………………………………………..…………… 59

Illustration of each participant………………………………………………………………….. 59 Overall results…………………………………………………………………………………………… 71

Objective 1…………………………………………………………………………………………… 71 Objective 2……………………………………………………………………………….….......... 71 Objective 3…………………………………………………………………………….…………….. 72 Results of Goal Attainment Scaling………………………………………………………. 73 Responders vs nonresponders……………………………………………………………… 76 Overall change pre to post-intervention………………………………………………. 77

Results of process Results of workshop feedback forms……………………………………………………. 78 Results of classroom observations……………………………………………………….. 78 Results of daily logs……………………………………………………………………………… 79 Discussion with teachers on sensorimotor strategies…………………………… 82 6. DISCUSSION AND CONCLUSION………………..……………………………………….....…………. 84 Limitations………………………………………………..…………………………………...………… 90 Implications for occupational therapy practice…………………………………………. 90 Directions for further research……………………………………………………….………… 91 Conclusion……………………………………………………………………………………..………… 92 REFERENCES………………………………………………………………………………….…………………….. 94 APPENDICES………………………………………………………………………………….…………………… i

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List of Figures

CHAPTER 2. Figure 1. Three enabling domains………………………………………………….…………. 15 Figure 2. The structured process of Occupational Performance Coaching ……………………………………………………………………….………….. 15 Figure 3. Taylor and Trott triangle………………………………………………….…………. 18 Figure 4. The process of sensory integration…………………………………………….. 20

CHAPTER 4.

Figure 5. Time line of procedures…………………………………………………..…………. 52

CHAPTER 5. Figure 6. Participant 1………………………………………………………………………………. 60 Figure 7. Participant 2………………………………………………………………………………. 61 Figure 8. Participant 3…………………………………………………………………….………… 62 Figure 9. Participant 4………………………………………………………………………………. 63 Figure 10. Participant 5………………………………………………………………….…………. 64 Figure 11. Participant 6…………………………………………………………………………….. 65 Figure 12. Participant 7………………..………………………………………………..…………. 66 Figure 13. Participant 8…………………………………………………………………………….. 67 Figure 14. Participant 9…………………………………………………………………………….. 68

Figure 15. Participant 10………………………………………………………………..………….69 Figure 16. Participant 11………………………………………………………………..………….70

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List of Tables

CHAPTER 4. Table 1. Example of an issue on COPM scaled into GAS…………………………… 53 CHAPTER 5. Table 2. Description of the participants……………………………………………………. 58 Table 3. Results of COPM-Performance and COPM-Satisfaction ………………. 71 Table 4. Results of Teacher Self-Efficacy Scale-CM……………………………………. 73 Table 5. Results of Goal Attainment Scaling……………………………………………… 74 Table 6. Example of a GAS goal ……………………………………………………..………….75 Table 7. Themes of GAS goals………………………………………………………..…………. 75 Table 8. Results of responders vs non-responders at post-intervention…………………………………………………………………………………….. 77 Table 9. Average and standard deviation of overall results (pre to post)………………………………………………………………………………….. 77

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List of Appendices A- Appraisal of resources on Alert Program® ………………………….…....…………. i B - Appraisal of resources on Sensorimotor Strategies ………..........……………v C - Teachers’ Sense of Efficacy Scale- subscale ……...……..……………….………… xxi D - Sample of Reliable Change Index calculation………………………………………. xxii E - Questions for post and follow-up debriefing….……………..…………………… xxiii F - OPC Stroke Fidelity Checklist……………………………………………………..………… xxiv G - Consent form for participants…………………………………………………..…………. xxix H - Outline of baseline/initial intake interview……………………………….………….xxxiii I - Intake questionnaire form……………………………..………....…………………………. xxxiv J - Classroom observation form………………………………………………………………… xxxv K - Outline of workshop ……………………………………...………………………..…………. xxxix L - Objectives and learning outcomes of workshop ……………………….…………. xl M - Slides from workshop …………………………………...…………………………………… xlii N - References from workshop …………….………………………………………………….. xcv O – Workshop feedback form………………….…………………………………….…………. c P - Outline of weekly OPC sessions …………………………........................………… ci Q - Daily log for participants……………………………….……………………………………. cvi R - IRB approval letter……………………………………….…………………………..…………. cvii S - ETSB approval letter …………………………………….………………………….…………. cix T - Letter to principals…………………………………………...……………………...…………. cx U - Recruitment letter for teachers……….…………………..…………………………….. cxi V – Goal attainment scaling goals…………………………………………………………….. cxii

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List of Abbreviations

ADHD- Attention Deficit Hyperactivity Disorder

ADHDT- Attention-Deficit/Hyperactivity Disorder Test

ASD- Autism Spectrum Disorder

BRIEF- Behaviour Rating Inventory of Executive Function

CBCL- Child Behavior Checklist

CDC- Center for Disease Control

COPM- Canadian Occupational Performance Measure

DCD- Developmental Coordination Disorder

ETSB- Eastern Townships School Board

GAS- Goal Attainment Scaling

IDEA- Individuals with Disabilities Education Act

IQ- Intellectual Quotient

MELS- Ministère de l’Éducation, du Loisirs et du Sports

OPC- Occupational Performance Coaching

P4C- Partnering for Change

RCI- Reliable Change Index

RCT- Randomized Control Trial

SP- Sensory Profile

SSC- Self-Regulation Checklist

TRF- Teacher’s Rating Form

TSES-CM - Teacher’s Self-Efficacy Scale- Classroom Management

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Glossary of Terms*

Action process: acts undertaken in order to reach a goal, a solution (Graham et al., 2006) Adaptive response: an effective or efficient behavioural response to a demand or a challenge (Lane, Miller, & Hanft, 2000) Burn out: “a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with other people in some capacity. Emotional exhaustion refers to feelings of being emotionally overextended and depleted of one's emotional resources” (Maslach, 1993, p.20) Classroom management: methods taken to create and maintain a learning environment conducive to successful instruction (e.g. arranging the physical environment, maintaining students’ attention and engagement, establishing rules) (Evertson, 2006) Classroom management self-efficacy: a teacher’s belief in their ability to organize and execute the actions needed to maintain order in the classroom (Brouwers & Tomic, 2000) Inclusive classroom: a regular education class where students with disabilities or those experiencing difficulties with learning or behaviour have been integrated (Bélanger & Gougeon, 2009) Inclusion: “a process that takes into consideration the diverse needs of the learner in order to maximize his or her participation in the learning process…” (Bélanger & Gougeon, 2009, p. 290) Knowledge translation: A “dynamic and iterative process that includes the synthesis, dissemination, exchange, and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products, and strengthen the healthcare system” (Canadian Institutes of Health Research, 2012, p. 1) Maladaptive classroom behaviours: ways of acting that will interfere with learning, disrupt others and may be unlawful or unsafe; may be expressed as emotional reactivity, anxiety, withdrawal, inattention, aggression, defiance (Hartley, Sikora, & McCoy, 2008; Myers & Holland, 2000) Occupational performance: the dynamic relationship between a person, their occupations and roles, and the environment they work, play and live (Law et al., 1996) Occupational Performance Coaching: a coaching intervention using collaborative problem solving to assist individuals to identify and implement effective ways to achieve their goals (Graham, Rodger, & Ziviani, 2009)

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Occupational role: This refers to the “rights, obligations, and expected behaviour patterns associated with a particular set of activities or occupations, done on a regular basis and associated with social cultural roles” (Townsend & Polatajko, 2013, p. 380) Occupational therapy: “is the art and science of enabling engagement in everyday living, through occupation; of enabling people to perform the occupations that foster health and well-being; and of enabling a just and inclusive society so that all people may participate to their potential in the daily occupations of life” (Townsend & Polatajko, 2007, p. 372) Self-efficacy: an individual’s belief in their ability to carry out a particular course of action (Bandura, 1997) Self-regulation: “is the ability to attain, maintain, and change arousal appropriately for a task or situation” (Williams & Shellenberger, 1996, p. 1-5) Sensory processing: a term that evolved from the work of Ayres (1972); it refers to the process and organisation of sensations to enable one to perform their daily occupations (Bundy & Murray, 2002; Miller, Anzalone, Lane, Cermak, & Osten, 2007a)

*Quotation marks indicate that the definition was taken directly from the source. The other definitions were based on the reported source.

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Preface

“…if you give a man a fish he is hungry again in an hour. If you teach him to catch a fish you do him a good turn…”

-Anne Ritchie

Chapter 1 is a brief introduction to the study. It describes what a teacher may face as the

consequence of the policy of inclusive education for students with special needs.

Chapter 2 is the literature review. It is subdivided into sections to make it easier to

understand.

Chapter 3 lists the objectives of the thesis.

Chapter 4 is a description of the methods of the study which includes the design,

participants, recruitment, measures, analysis, confidentiality and ethical considerations.

Chapter 5 is a report on the results.

Chapter 6 is a discussion of the results, limitations, the contribution to the profession, and

the conclusion.

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Chapter 1: General Introduction

A major shift occurred in the education of students with special needs in Canada in the mid-

1980’s: the Canadian Teacher’s Federation began implementing controversial policies of

inclusive education (Hutton, 2009; Winzer & Mazurek, 2011). Hence, today’s elementary school

teachers in the regular classroom face, on a daily basis, students with a multitude of needs.

These students may present with disruptive classroom behaviours1 such as temper tantrums,

poor attention span, low energy level, overly nervous or anxious temperament and impulsive

actions. With increasing class sizes and a growing number of students with specific learning

needs, these behaviours can become overwhelming. Among teachers, this disruption of the

classroom environment can contribute to decreased self-efficacy, emotional exhaustion,

burnout and overall stress (Boyle, 1995; Chan, 1998; Klassen & Chiu, 2010; McCormick &

Barnett, 2011; Skaalvik & Skaalvik, 2010). Evidence has shown a direct relationship between the

prevalence of behaviour problems of students and teacher burnout (Geving, 2007; Hakanen,

Bakker, & Schaufeli, 2006; Kokkinos, 2007).

Because of the growing prevalence of students with disruptive behaviours in the regular

classroom and the impact of an increased workload on teachers, occupational performance

among teachers may be compromised. The term occupational performance describes the

dynamic interplay between a person, the environment in which they live, play and work and

their roles and occupations (Law et al., 1996). Teachers need support in order to successfully

meet the diverse student needs. However, the school-based occupational therapist’s role has

1 ways of acting that will interfere with learning, disrupt others and may be unlawful or unsafe; may be expressed as emotional reactivity, anxiety, withdrawal, inattention, aggression, defiance (Hartley et al., 2008; Myers & Holland, 2000)

1

traditionally been to address the needs of individual students. Perhaps a change of the target

for service delivery for resource services is needed. In fact, identifying the whole school as the

client rather than individual students has been found to be beneficial (Hutton, 2009; Missiuna

et al., 2012). Further, previous studies have identified the teacher as a key player by presenting

the underlying causes for students’ disruptive classroom behaviours and demonstrating specific

strategies to address them (Mulligan, 2001; Worthen, 2010). However, there are no known

studies where occupational therapists have focused on the needs of the teacher.

Any changes in the service delivery of school-based occupational therapists should benefit

both teachers and students. Presently, service delivery takes place directly, indirectly, or

through consultation depending on students’ needs and the environment. In North America,

there is a growing trend to adopt a consultation service delivery model (Case-Smith & Bazyk,

2010; Jackson, Polichino, & Potter, 2006; Reid, Chiu, Sinclair, Wehrmann, & Naseer, 2006).

However, not only are there are no specific guidelines for a consultation model for school-

based occupational therapists, research has shown that the results of consulting fail, not

because of the lack of expertise on the part of the consultant but, rather, because of the lack of

implementation of recommendations once the consultant is absent (Lewis & Newcomer, 2002).

Perhaps we should move away from expert consulting model where an expert offers

recommendations and then leaves, to a coaching model where the teacher is enabled in the

development of their own expertise.

Occupational Performance Coaching (OPC) is an occupation-centered intervention where

both parties are of equal importance. It uses three enabling domains to support the client in

achieving their goals: emotional support, information exchange and a structured process. This

2

problem solving process helps the client find ways to improve the dynamics between

themselves, their environment and their occupation (Graham & Rodger, 2010). It empowers

their problem solving skills. Thus, OPC seems suited as an alternative approach used by school-

based occupational therapists with teachers.

Knowing that the number of special needs students continues to grow (Lewis & Newcomer,

2002; Noiseux, 2008), it is imperative that teachers are supported in their occupational role2

and performance as a preventive measure against burnout and the retention of novice

teachers. Therefore, this study aimed to examine the extent to which a one day workshop

followed by Occupational Performance Coaching sessions can be used with teachers to improve

their perceived occupational role when faced with the demands of teaching students with

disruptive classroom behaviours.

This master’s thesis used the framework of the Knowledge to Action Process as a guide for

its structure (Graham et al., 2006). It began by describing teachers’ workload, stress and self-

efficacy (identification of the problem). Research supporting teachers’ challenges in their tasks

was presented and a description of the regular classroom provided. The question of what can

be done was posed and objectives of the study were stated. The thesis continued by presenting

a solution and an action process. A review of research on the role of occupational therapists in

the schools, Occupational Performance Coaching, sensory processing and self-regulation, the

Alert Program®, and sensorimotor strategies was presented. Supporting literature for effective

knowledge translation was described. Then the study’s methods of evaluating knowledge use

2 This refers to the “rights, obligations, and expected behaviour patterns associated with a particular set of activities or occupations, done on a regular basis and associated with social cultural roles” (Townsend & Polatajko, 2013, p. 380)

3

and outcomes were presented. The final chapter was a discussion of the results, limitations,

clinical relevance, and implications for further research.

4

Chapter 2: Background

Heterogeneity of Students in Regular Classrooms

Throughout Canada, ‘mainstreaming’, or inclusive education, has become the mantra of

educational policy for students with special needs. Founded on social-ethical considerations,

children’s human and educational rights were at the foreground of policy-making in the mid-

1980’s and continue to draw much attention (Winzer & Mazurek, 2011). Inclusion can be

defined as “a process that takes into consideration the diverse needs of the learner in order to

maximize his or her participation in the learning process, in school....” (Bélanger & Gougeon,

2009, p. 290). This definition clearly stated the intention that inclusive education took the

needs of the learner into consideration, but what has the impact of these policies been on the

occupational performance and self-efficacy of the classroom teacher?

In today’s regular elementary schools, where inclusion is now the norm, the average

elementary school teacher oversees a complex learning environment and a myriad of

differentiated student learning needs. Classes can include a heterogeneous mix of students

with special needs such as significant learning disabilities, cognitive delays, and a wide range of

social and behaviour difficulties. Some students may have received diagnoses, while others

remain undiagnosed or are waiting for diagnostic evaluations.

Specifically, Autism Spectrum Disorders (ASD) was recognized as the most prevalent

paediatric neurological disorder in Canada, such that 1 in 50 children were diagnosed with ASD

(Centers for Disease Control, 2013). From 2003 to 2010, a trend for increased prevalence of

ASD among 2 to 14 year olds was reported in Newfoundland, Southeastern Ontario and Prince

Edward Island (Ouellette-Kuntz, Coo, & Gorski, 2012). In 2003, the prevalence of ASD in the

5

Lester B. Person School Board in Montreal, QC, was 64.9 out of 10 000 for students from

kindergarten to Grade 11 (Fombonne, Zakarian, Bennett, Meng, & McLean Heywood, 2006). In

2007-2008, 1/178 students in Quebec, had a diagnosis of ASD. Since 2000-2001, an annual

prevalence growth of 23% was represented . Although, in 2007-2008, there was an overall

decrease in student numbers, 868 more students with ASD were registered in schools than

during the previous year (Noiseux, 2008).

Worldwide, an estimated 5.3% of children were reported to have Attention Deficit Disorder

Hyperactivity Disorder (ADHD)(Centers for Disease Control, 2010; Polanczyk, de-Lima, Horta,

Biederman, & Rohde, 2007). ADHD was the most prevalent Canadian paediatric psychiatric

disorder affecting 5-12% of school-aged children (Canadian ADHD Resource Alliance, 2012;

Langlois, Samokhvalov, Rehm, Spence, & Connor Gorber, 2012). Similarly, in the United States,

ADHD was the most prevalent psychiatric disorder in children with rates increasing yearly with

nearly one in ten children presently diagnosed with ADHD. (Centers for Disease Control, 2010;

Polanczyk, de-Lima, Horta, Biederman, & Rohde, 2007). Learning limitations such as attention,

hyperactivity and dyslexia affected 3.2% of Canadian children between the ages of 5-14 years

(Participation and Activity Limitation Survey, 2006).

In Canada, 61% of children with special needs were in regular education classes. In Quebec,

the enrollment of special needs students in regular education classes rose to 65% (Participation

and Activity Limitation Survey, 2001). The number of these students increased yearly. In 2009,

18.4 percent of the student population were identified as having special needs as compared to

13.5 per cent in 2003 (Ministère de l’Éducation, 2009).

6

Identifying the Problem

Teacher Workload

The increasing prevalence of children with special needs in the regular classroom makes a

teacher’s role more challenging and complex, especially in more rural school boards where

support services can be limited. In 2001, the Canadian Council for Children with Disabilities

reported that, in rural areas across the country, there was an insufficient level of educational

support staff (Kohen, Uppal, Khan, & Visentin, 2010). A pilot study of teachers from Calgary

reported that resources and support were minimal despite a teaching mandate for an

increasingly diverse population (Naylor, 2012). Several other task forces, which looked at

teachers in different Canadian provinces, identified the challenge of supporting the needs of a

wide variety of students (Alberta Teachers’ Association, 2012; Dyck-Hacault & Alarie, 2010;

Elementary Teachers’ Federation of Ontario, 2009; MacDonald, Wiebe, Goslin, Doiron, &

MacDonald, 2010; Manitoba Teachers' Society, 2007). A Canadian Teachers’ Federation poll

indicated that 30% of respondents cited lack of resources and access to experts as stumbling

blocks to the success of certain students (O'Connor, 2004). In British Columbia, a large number

of teachers felt that they were not professionally prepared to teach such a wide variety of

students (Naylor, 2003). More recently, a national survey indicated that increasing demands on

the workload (80% of responders) and lack of support regarding students with special needs

(58% of responders) were important factors influencing novice teachers to leave the profession

(Canadian Teachers’ Federation, 2011).

It is clear that teachers are expressing a discontent about the demands they face regarding

more heterogeneous classes and the lack of support. The prevalence of students with special

7

needs is increasing and the expectations placed upon teachers have not changed, they must

meet the needs of all students. What will happen to the well-being of the teachers?

Teacher Stress

Added to the complexity of the task of teaching, the demands of diverse student needs

without adequate support and the subsequent increase in workload were found to lead to

increased responsibilities and increased stress levels among teachers (Schaefer, 2003; Winzer &

Mazurek, 2011) which would have had a negative impact on occupational performance.3

Disruptive student behaviour was recognized as an important work related stressor for teachers

(Boyle, 1995). Student misbehaviour was rated as the second most important factor causing

stress among Hong Kong teachers (n=400) (Chan, 1998). In another study of teachers, (n=416),

stress was negatively related to a personal sense of accomplishment and the inability to

successfully manage student behaviours proved to be exhausting (McCormick & Barnett, 2011).

Only 13% of responders to the Canadian Teachers’ Federation (2011) survey felt they were

satisfied in how they could deal with behaviour issues. Because behaviours were varied and

were often unpredictable in students with poor self-regulation, decreased levels of satisfaction

were noted in working with such children (Cohn, May Benson, & Teasdale, 2011). Hence, stress

can clearly impact the teachers’ satisfaction of their occupational role, thus impacting their

occupational performance.

3 Occupational performance can be defined as the dynamic relationship between a person, their occupations and roles, and the environment they work, play and live (Law et al., 1996).

8

Emotional exhaustion, which may be caused by stress, was a central element to teacher

burnout4 (McCormick & Barnett, 2011; Skaalvik & Skaalvik, 2010). Significant correlations were

found between behaviour problems of students and measures of teacher burnout (Geving,

2007; Hakanen et al., 2006; Kokkinos, 2007). In Quebec, data from the Ministère de l’Éducation,

de loisirs et du sports, showed that absenteeism and long-term leave had increased among

Quebec teachers (Canadian Broadcasting Corporation News, 2009). The Central des syndicats

du Québec, the union responsible for most teachers in the province, attributed the increased

absences and long-term leave to teacher exhaustion. Teachers stated that integration of

students with special needs into their classroom was more demanding for them (Canadian

Broadcasting Corporation News, 2009). Insurance claims released by the Quebec Provincial

Association of Teachers reported that their long term disability leaves had risen over the past

20 years. Recent claims indicated that 31-33% of teachers were on leave due to classroom

stress and burnout (A. Lombard, personal communication, October 15, 2013). In British

Columbia, the prevalence of Salary Indemnity Plan claims due to stress-related disorders

represented 47% of the program’s total costs (Naylor & Vint, 2009).

In summary, a synthesis of the literature around the teaching burden associated with the

Canadian policy of ‘mainstreaming’ showed that the management of disruptive classroom

behaviours was a cause of teacher stress and dissatisfaction which had potential to negatively

impact a teacher’s occupational role and performance (Mulligan, 2001; Worthen, 2010).

4 “a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with other people in some capacity. Emotional exhaustion refers to feelings of being emotionally overextended and depleted of one's emotional resources” (Maslach, 1993, p.20)

9

Self-Efficacy of Teachers

Bandura, a leading social scientist, stated that knowledge and skill were not the only factors in

achieving one’s goals. He proposed that the belief that one can succeed was instrumental in the

process. Accordingly, self-efficacy was described as an individual’s belief in their capabilities to

successfully plan, organize and carry out a particular course of action in order to achieve their

goals (Bandura, 1997; Skaalvik & Skaalvik, 2010). However, findings on teacher stress and self-

efficacy supported the expectation that teachers with greater classroom stress had less self-

efficacy, especially in classroom management self-efficacy (Klassen & Chiu, 2010). Classroom

management self-efficacy has been defined as a teacher’s belief in their ability to organize and

execute the actions needed to maintain order in the classroom (Brouwers & Tomic, 1998).

Teacher self-efficacy, as measured by the Norwegian Teacher Self-Efficacy Scale, was negatively

correlated (r=-0.76) with burnout (Skaalvik & Skaalvik, 2007). Therefore, classroom

management self-efficacy was compromised by stress and fatigue.

This evidence, in combination with that which supported the negative impact that the

integration of special needs students with disruptive classroom behaviours had on stress and

fatigue amongst teachers, suggested a need to implement a solution to improve the classroom

management self-efficacy of elementary school teachers.

Solution/Action Process

The evidence above provided an illustration that teachers’ occupational roles were not

getting any easier. There was an ongoing demand to meet the needs of all the students,

regardless of their diagnosis. Support services were not increasing. This research project

investigated how occupational therapy can help support the teachers in their occupational roles

10

to improve their occupational performance with classroom management with students with

special needs, specifically disruptive classroom behaviors.

Occupational Therapy

“Occupational therapy is the art and science of enabling engagement in everyday living, through occupation; of enabling people to perform the occupations that foster health and well-being; and of enabling a just and inclusive society so that all people may participate to their potential in the daily occupations of life” (Townsend & Polatajko, 2007, p. 372)

School-based occupational therapists are in the position to help teachers with their

occupational performance to improve their ability to manage students with challenging

behaviours. Hence, the occupational therapist can enable the teacher in their occupational role

in the classroom.

In the United States, the Individuals with Disability Education Improvement Act (IDEA, 2004)

required related services such as occupational therapy to meet the educational needs of

students with disabilities. In Canada, no similar legislation existed, therefore occupational

therapy services were not legislated in the school system and services differed from one

province to another. Service delivery models used were direct or indirect intervention or

through consultation depending on students’ needs and the environment. Traditionally,

occupational therapists working in schools focused on the needs of specific students. More

recently, the consultation model has grown as the favoured service delivery model (Case-Smith

& Bazyk, 2010; Jackson et al., 2006; Reid et al., 2006). However, the focus of intervention

remained on the needs and the role of students, rather than on their teachers.

Nonetheless, a shift occurred in the focus of school-based occupational therapy intervention

based on recommendations to identify teachers as the target for intervention (Mulligan, 2001).

11

In Canada, Partnering for Change (P4C) was an example of a school health service delivery

model for children with Developmental Coordination Disorder (DCD) with the school as the

client (Missiuna et al., 2012). The objective of P4C was to transfer knowledge to ensure

teachers acquired information and skills to better support students with DCD. A study of

occupational therapists using P4C as a service delivery model reported positive results on

several themes: strong professional growth, becoming part of the school community, successful

partnerships with teachers, providing services that make an impact in the school system

(Campbell, Missiuna, Rivard, & Pollock, 2012). In the United Kingdom, a pilot project examined

providing services to the whole school, rather than targeting individual children. Teachers who

participated in this pilot study indicated that, through the sharing of knowledge and skills by

regular contact with the occupational therapist, actual changes were brought to their teaching

practice and, subsequently, impacted students’ learning and engagement (Hutton, 2009).

The research on working with the teachers to help their students rather than working

directly with the students is promising. However, the focus remains on the students’ goals, not

those of the teachers.

Collaboration between Occupational Therapists and Teachers

Several studies have examined the collaboration of occupational therapists and teachers to

benefit the student. A review of ten studies describing collaboration in school settings reported

that both direct one on one intervention and consultation were effective in influencing student

functional performance and goal achievement. However, teachers were more satisfied with

these interventions when they were classroom-based (Sayers, 2008). There was an association

between increased collaborative services and improved teacher understanding of the role of

12

the occupational therapist. Consultation ensured carryover of interventions into the classroom

(Sayers, 2008). In another review of 11 studies on collaborative consultation in school-based

occupational therapy, consultation was described as a collaborative process between the

therapist and educator in order to identify goals, develop strategies, and monitor student

progress (Villeneuve, 2009). The student outcomes used in the majority of the studies under

review relied on teacher ratings of student achievement. Positive correlations between the

teachers’ perception of occupational therapy contributions to skill development of the students

and successful education outcomes suggested that these were influenced by collaborative team

practice (Barnes & Turner, 2001; Villa, Thousand, Nevin, & Malgeri, 1996). These findings were

further supported by insight into factors influencing therapist-educator collaboration (Bose &

Hinojosa, 2008; Case-Smith & Cable, 1996; Fairbairn & Davidson, 1993; Nochajski, 2001;

Wehrmann, Chiu, Reid, & Sinclair, 2006). A Canadian study investigating reported occupational

changes in the fine motor skills of school aged children after occupational therapy school-based

consultation reported positive results (Wehrmann et al., 2006).

Lack of time to meet, lack of presence of the occupational therapist at school, and confusion

about what can be expected from the therapist were revealed as barriers to collaboration

(Hinder & Ashburner, 2010). It was recommended by teachers that occupational therapists

spend more time in the classroom (Case-Smith & Cable, 1996; Fairbairn & Davidson, 1993). In

order to develop educationally relevant approaches for the students, a clear understanding of

roles and responsibilities of the occupational therapist was required, including awareness of the

schools’ policies, curriculum and classroom practices (Casillas, 2010; Villeneuve, 2009). A study

on South Australian occupational therapists concluded that therapists knew what collaboration

13

was but agreed that it was not occurring as frequently as it should (Kennedy & Stewart, 2012).

There was a discrepancy between optimal levels of collaboration and the current practice.

Although all these studies pertained to consultation or collaboration, the methods were not

clear. Several collaborative approaches to working with teachers have been cited in the

education field (Hsieh, Hemmeter, McCollum, & Ostrosky, 2009). However, no specific

approaches were designed to guide the collaborative consultation of therapists with teachers. A

specific framework such as a coaching intervention with guidelines could be part of the

solution.

Occupational Performance Coaching

Occupational Performance Coaching (OPC), an example of a collaborative approach, was

developed as a way for occupational therapists to support parents in achieving goals for

themselves and their children. A ‘top down’ approach to clinical reasoning, based on family-

centred principles (Rosenbaum, King, Law, King, & Evans, 1998), using coaching techniques

(Rush, Shelden, & Hanft, 2003) and solution-focused interviewing (De Jong & Berg, 2008) and

beginning with an exploration of occupational roles and competence was described by Graham

(Graham et al., 2009). Three enabling domains were used in OPC: emotional support,

information exchange, and structured process (Figure 1).

14

Figure 1. Three enabling domains (Graham & Rodger, 2010, p. 203)

The structured process of OPC is based on the interaction between the person, the

environment, and the occupation (Figure 2).

Figure 2. The structured process of Occupational Performance Coaching (Graham & Rodger, 2010, p. 218)

Generalise Set Goal

person

Check Performance

environment

task

Explore Options

Carry Out Plan

Plan Action

Doable Likely to work

15

Research using OPC in a mixed methods design examined its effect on improving the

occupational performance of parents and their children. The parents (n=29) of children with

special needs indicated significant improvement with their sense of competency in their

parental role as measured by the Parent Sense of Competency Measure (effect size=0.65) and

in their self-competence in specific goals as measured by the Specific Parenting Efficacy and

Satisfaction Measure (effect size=1.87). As well, using Goal Attainment Scaling (GAS), results

indicated that the parent’s performance for specific goals improved significantly (p=0.003).

Parent performance and satisfaction, as measured by the Canadian Occupational Performance

Measure (COPM), indicated significant change (p=0.002, p=0.003, respectively) (Graham, 2010).

Further research evidence supported the use of OPC to improve children’s occupational

performance and parent wellbeing. In a descriptive case study, performance satisfaction of

occupational performance were measured to be clinically significant using GAS and COPM

(Graham, Rodger, & Ziviani, 2010).

Although developed to be used with parents, similar principles apply to teachers and OPC

was used in an exploratory study in Germany with preschool teachers (n=3) to help improve

play skills in children with Developmental Coordination Disorder (DCD). This multiple case

replication design supported OPC’s effectiveness in raising awareness of issues surrounding

occupational performance difficulties and in generating solutions to those difficulties. All

teachers reported the benefits of using OPC. They reported seeing the situation differently.

They felt supported; they were able to transfer the skills they learnt to benefit children other

16

than the ones they had targeted for the study. (Kennedy-Behr, Rodger, Graham, & Mickan,

2013) .

Weekly follow-up applies well to the OPC model (Graham & Rodger, 2010) as well as

consulting in the schools (Noell et al., 2005). An intervention of eight sessions is feasible in the

school system and provided time to generate a reschedule if needed. Other studies have used

similar lengths of intervention (Barnes, Vogel, Beck, Schoenfeld, & Owen, 2008; Chiodo, 2010;

Graham et al., 2010; Miranda, Maria Jesus, & Soriano, 2002).

OPC takes into consideration all the recommendations on how to improve occupational

therapist and teacher collaboration/consultation previously mentioned: clearer roles between

the teacher and therapist, increased frequency of classroom visits and collaboration by the

occupational therapist, and the therapist’s increased awareness of school policies and

classroom procedures. Collaborating with the teacher within their work environment may

serve to make it more meaningful and ensure that the occupational therapist understand the

demands of the class in order to better assist the teacher to improve their occupational

performance and self-efficacy (Hinder & Ashburner, 2010; Hutton, 2009). As well, OPC is more

than collaboration. It follows recommendations on knowledge translation and facilitating

change by allowing them control over the process of goal attaining, opportunities for self-

monitoring and active problem solving (Graham et al., 2006; Thomas, Saroyan, & Dauphinee,

2011). OPC looks at the dynamic interaction of the person, their environment and their

occupation and it uses a structured process which encompasses methods suited to adult

learning and knowledge uptake. It can be a very useful approach for school-based occupational

17

therapists. Thus, in this research study, OPC was the intervention of choice to support teachers’

occupational roles and performance.

Sensory Processing

Sensory processing refers to the neurological process within an individual that organizes

sensations from the body and the environment to enable performance of successful adaptive

responses to situational demands (Ayres, 1972; Miller et al., 2007a). According to the

theoretical model of sensory processing, illustrated in Figure 3, the sensory systems form the

foundation for higher level cognitive functions such as behaviour and learning (Williams &

Shellenberger, 1996). Hypothesized to influence temperament and personality, sensory

processing may thus have an impact on a child’s ability to control or regulate their behaviours

in the classroom (Dunn, 2001; Greenspan, 2009).

Figure 3- Taylor and Trott Model of the Central Nervous System (Williams & Shellenberger, 1996, p. 1-4)

18

Ayres believed that the different sensory systems work together to form a neurological basis

for the daily functions a child needs to be successful in his childhood roles (Ayres, 2005). In

order to be able to concentrate, to be organized, to exhibit self-control and self-confidence, to

learn, to think and reason, and to develop specialization of the brain and body, the basic

sensory systems must be functioning adequately (Figure 4).

Recent research supported the neurological or biological basis for sensory processing issues.

Using electroencephalographic measures with children, it was found that immaturity or

malfunctions in brain processing result in behaviours relating to sensory processing dysfunction

(Davies & Gavin, 2007). Firm neuroanatomic underpinnings for the symptoms of sensory

processing issues were found (Koziol, Ely Budding, & Chidekel, 2011). A more recent study using

diffusion tensor imaging found abnormal white matter microstructure in children with sensory

processing disorders. This reduced posterior cerebral tract white matter correlates directly with

the atypical sensory-based behaviours observed (Owen et al., 2013). Hence, almost four

decades after Ayres, there is some scientific evidence to support the theory of sensory

processing disorders.

19

Figure 4. The Process of Sensory Integration (Ayres, 2005, p. 55)

Impact of Sensory Processing on Student Behaviour

Thus, in addition to specific issues within the challenges of academic learning itself, students

with special needs may have differentiated responses (i.e. overreaction or under reaction) to

the sensory environment of the classroom (e.g. noise, visual distraction). These reactions may

reflect issues with the child’s underlying sensory processing systems (i.e. visual, auditory, tactile,

movement, and proprioception) which may influence classroom behaviours and impact

learning (Dunn, 2007; Koziol et al., 2011; Miller, 2006; Miller, Reisman, McIntosh, & Simon,

2001; Watling, Davies, Patten Koening, & Schaaf, 2011).

Disruptive behaviors associated with the child’s hypo or hyper- sensory responsiveness to

the classroom environment may negatively affect his participation in daily classroom activities

20

(Blanche, Reinoso, Chang, & Bodison, 2012). A student with a hypo-responsive sensory

processing issue may seek out sensations such as movement or touch to compensate for their

own dampened responses in these areas. These students may need more sensation in order to

generate an adequate perception of proprioceptive feedback from their joints and muscles in

their bodies (Dunn, 2007; Miller, 2006). For example, decreased proprioception, often present

in children with ASD, includes behaviors such as tiptoeing, pushing others or objects, falling,

crashing purposefully and running which may be perceived as disruptive by some teachers

(Weimer, Schatz, Lincoln, Ballantyne, & Trauner, 2001). Certainly, some disruptive behaviour

may be seen as maladaptive or acceptable depending on the expectations of the teacher and

the situation or environment. Students who are constantly humming, moving on their chair and

getting up to work may not be accepted in the library or tolerated by teachers who require

their students to sit quietly and work. On the other hand, the students’ behaviours would not

be considered maladaptive at a birthday party or in a class where the teachers are more

tolerant. However, when behaviours are deemed unacceptable, it is vital for teachers to

understand the possible underlying reasons of the maladaptive behaviours and find ways to

help the students modify their behaviours.

Knowing that students with special needs are in regular classrooms, it is important to

determine if they may have underlying sensory processing difficulties as well as a specific

diagnosis. Among the heterogeneous mix of students’ needs teachers face in their classrooms,

students with ASD (Ben Sasson et al., 2009b; Blanche et al., 2012; Jasmin et al., 2009; Suarez,

2012), ADHD (Barkley, 2006; Crundwell, 2005; Kofler, Rapport, & Alderson, 2009), Intellectual

Developmental Disorder (Engel, Hardal-Nasser, & Gal, 2011), or gifted students (Ben Sasson,

21

Carter, & Briggs Gowan, 2010; Gere, Capps, Mitchell, & Grubbs, 2009) have been shown to

present with sensory processing issues. As well, a more recent study indicated that children

with ASD + ADHD have poorer sensory processing skills than those with ADHD alone (Mattard

Labrecque, Ben Amor, & Couture, 2013). Students with Specific Learning Disabilities were

shown to exhibit sensory processing issues that created learning and behavioural challenges

(Dove & Dunn, 2008). In addition, 81% of children with Fetal Alcohol Spectrum Disorder were

reported to have sensory processing problems (Abele-Webster, Magill-Evans, & Pei, 2012). Two

large studies in the United States reported that sensory processing disorders were affecting 5-

13% of children 4-6 years old (n=710) and 17% of 7-11 year olds (n=925) who did not have a

diagnosis (Ahn, Miller, Milberger, & McIntosh, 2004; Ben Sasson, Carter, & Briggs Gowan,

2009a).

With this kind of representation in the population, clearly these children are present in every

classroom. Hence, teachers must deal with the learning issues pertaining to specific diagnoses

as well as the behaviour issues that may arise from the attendant sensory processing issues.

Their understanding of the impact of impaired sensory processing on behaviour is vital on how

to better manage the behaviours of the students.

The studies reviewed above, which looked at the prevalence of sensory processing disorder,

varied extensively in sample size. The studies on the prevalence of sensory processing disorders

with the ASD population had larger sample sizes and were more rigorous than those with other

diagnosis. A meta-analysis and critical review were available for ASD and the presence of

sensory processing issues (Ben Sasson et al., 2009b; Rogers & Ozonoff, 2005). As well, the

Diagnostic and Statistical Manual of Mental Disorders (5th ed.) has been revised to include

22

sensory issues as part of their diagnostic criteria for ASD (American Psychiatric Association,

2013). Hence, this further established the presence of sensory processing issues with that

population. In contrast, few studies have been done looking at the prevalence of sensory

processing issues in children with Specific Learning Disabilities (n=37) (Dove & Dunn, 2008) or

Fetal Alcohol Disorders (n=26) (Abele-Webster et al., 2012). The studies on Intellectual

Developmental Disorder and sensory processing (n=91) (Engel et al., 2011) and on gifted

students (n=80) (Gere et al., 2009) had slightly larger sample sizes. More research has focused

on the prevalence of ASD and sensory processing since the prevalence of these students is

growing in regular classrooms. Hence, there is a need to find intervention frameworks for that

population and to help teachers work with them successfully.

Sensory Processing Impacts Self-Regulation

Self-regulation is defined as the ability to attain, maintain and change the state of one’s

arousal level to be able to attend to the task at hand (Schaaf et al., 2010; Williams &

Shellenberger, 1996). It helps us modulate the intensity, frequency, and duration of verbal and

motor acts. Self-regulation is vital to success in school (Shanker, 2012). To be successful in

school, children must develop the abilities that will help fulfill their student role: willingness to

play by the rules, follow the teacher’s instructions, and respect the space of others (Karpov,

2005), all abilities that require self-regulation. Without it, success in school is compromised and,

to some theorists, it is considered a more important indicator of educational performance than

IQ (Blair & Diamond, 2008; Duckworth & Seligman, 2005). Self-regulation can be viewed as

having five domains: biological/neurological, emotional, cognitive, social, and prosocial

(Shanker, 2012). Within the biological domain, the sensory systems form the foundation for

23

higher level cognitive functions, creating the basis for the student’s ability for self-regulation. If

a student has difficulties in the underlying biological domain, it becomes more likely that issues

in emotional, cognitive, social, and prosocial may arise.

Thus, self-regulation is dependent on sensory processing abilities (Parham & Mailloux, 2010;

Watling, 2010) and plays a large role in how a student is able to control his behavior in the

classroom (Greenspan, 2009). Impaired sensory processing will impact the ability for self-

regulation (Dunn, 2007; Koziol et al., 2011; Miller, 2006; Miller et al., 2001; Watling et al.,

2011).

For example, a student with sensory processing difficulties may become physiologically over

aroused due to intense environmental stimuli such as ambient noise, flickering lights, frequent

accidental touch. The student’s response may manifest as maladaptive behaviour: aggression,

self-injurious behaviours, avoidance, or withdrawal. The student’s inability to modulate the

state of his arousal level to be able to attend to the task at hand is compromised. In this

example, the underlying sensory processing issues are associated with poor self-regulation

which manifests as disorganized and maladaptive classroom behaviours. This scenario can lead

to greater behaviour issues in high school: violence towards others, damaging school property,

severe negative behaviours, abusive of drugs and alcohol (Geving, 2007; Jones, Dodge, Foster,

& Nix, 2002).

In summary, the disorganized and challenging behaviours exhibited by students due to poor

underlying sensory processing and impaired self-regulation will impact the student’s learning as

well as affect the teacher’s occupational role and performance.

24

These studies, although not numerous, were vital for this study. They served to support the

impact that poor sensory processing affects self-regulation, which impacts student behaviour in

the classroom. Work on self-regulation in Canada was a key factor in building this study with

teachers since concrete examples in schools were described (Shanker, 2012).

Self-regulation and Demands on the Teacher

As previously mentioned, the regular classroom is made up of a variety of students and each

has their particular needs. Students with sensory processing and self-regulation issues

contribute to the challenging mix of behaviours a teacher faces in the classroom; classroom

management becomes more challenging. These issues contribute to teacher workload and

stress which affects their occupational role and performance (Miller, 2006; Skaalvik & Skaalvik,

2010).

Occupational therapists have the expertise to work with individuals to improve their

occupational performance. As well, they have an understanding of sensory processing and self-

regulation and can provide intervention for these difficulties. Specific programs have been

developed by occupational therapists to work with self-regulation in schools.

The Alert Program®

The Alert Program® was developed in the 1980’s by occupational therapists Shellenberger

and Williams to teach children about self-regulation; it uses cognitive learning and

sensorimotor strategies to improve self-regulation and it is considered a sensory-based

intervention (Watling et al., 2011). An innovative program, it is based on the fundamental

principles of sensory processing and it uses sensory activities or sensory tools as vehicles for

25

self-regulation. In this study, the Alert Program® was part of the training given to teachers to

help with classroom management. The Alert Program® was chosen as a model because it was

easy for teachers to understand and apply in class; other sensory processing interventions did

not lend themselves to school-based interventions as easily.

Students, therapists, teachers and parents learn about and apply self-regulation strategies to

attain and maintain the attention, or alertness, needed to attend to a task (Williams &

Shellenberger, 1996). The Alert Program® provides a learning analogy based on the rationale

that our bodies are like engines: sometimes they run on ‘fast-high’, sometimes on ‘slow-low’

but efficiency (i.e. learning) takes place best when the engine runs ‘just right’. ‘Engine changing

activities’ are divided into five methods. Students, teachers and/or parents are taught that you

can change your engine levels by (1) putting something in your mouth or using your breath, (2)

moving which includes vestibular and proprioceptive input/heavy work, (3) touching (e.g.:

fidgeting, deep touch, temperature variations), (4) looking (e.g.: variations in light, colour,

decrease visual distractions), and (5) listening (e.g.: music, variations in rhythm or noise

reducing headsets). These strategies are used to support self-regulation and facilitate optimal

attention for learning. The Alert Program® can help students find more acceptable ways to self-

regulate as opposed to using maladaptive ways such as chewing their hair, moving constantly,

rocking back on their chair, talking loudly or other unacceptable behaviours as deemed by their

teachers. Using sensorimotor strategies as vehicles for self-regulation can help students

produce an adaptive response suited to the demands of the situation and the environment.

Since the Alert Program® was used in this research, it is important to review how it was used

in other studies. In a Randomized Control Trial (RCT), the Alert Program® was adapted to be

26

used as part of a 12 week neurocognitive habilitation with children with fetal alcohol spectrum

disorders. Participants (n=78) were randomized to either a treatment group or a control group

using single random assignment by means of a table of odd and even random numbers

(treatment group: n=40; control group n=38). Results of the Behaviour Rating Inventory of

Executive Function showed significant improvement in the treatment group due to the

intervention. (Wells, Chasnoff, Schmidt, Telford, & Schwartz, 2012). Using the PEDro Scale5 for

RCT’s, this research scored 7/10 (PEDro, 1999).

In a recent study, the Alert Program® was used with two kindergarten classes in two

different schools. Improvements were found in behaviours and self-regulation in the students

who received intervention (Buchanan, 2011). Statistically significant results were found on the

School Functional Assessment- Part III Activity Performance Cognitive/Behavioral Tasks

indicating that the treatment group improved significantly on five of the nine areas.

Use of the Alert Program® to improve students’ attention was implemented in a self-

contained classroom of eight students with one teacher and two para-professionals. The Alert

Program® was introduced in three phases over a six week period. Qualitative analysis indicated

that the Alert Program® increased teacher’s awareness of self-regulation which helped them

identify a students’ arousal level and find ways to optimize it (Chiodo, 2010). Quantitative data

on the amount of redirections to task required for each student decreased on five of the six

students remaining in the study and time on task increased by 25% for six of the students

(Chiodo, 2010).

5 The PEDro scale was created by the Centre of Evidence-Based Physiotherapy. It is an 11 point scale of which 10 points assess the internal validity of a study (question 1 is not part of the total score on 10).

27

In a pre-post design study of the Alert Program® with 7 to 10 year old students (n=7), six

with ASD and one with ADHD, results indicated that the use of sensorimotor strategies to help

students focus was effective. The Teacher Observation Scale and the Student Self Report Scale,

both designed for this study, showed significant progress; students became more aware of their

sensory needs to focus and attention to task was improved (Zeidler, 2012).

In an exploratory study, the impact of using the Alert Program® with students (n=7) with

emotional disabilities for eight weeks found positive results (Barnes et al., 2008). An effect size

of 0.18 for the group responses on child self-reported measures of self-regulation and self-

efficacy was reported. Analyzing teacher responses on the Teacher Perceptions of Student’s

Efficacy in Self-Regulation, indicated that the group effect was significant (ρ=0.04) with an

effect size of 0.36. This exploratory study reported a trend that the Alert Program® was

effective in improving a student’s ability to self-regulate as indicated by changes on the Sensory

Profile, Devereux Behavior Rating Scale-School Form, Self-Efficacy for Self-Regulation of School

Aged Children, and the Teacher Perceptions of Student’s Efficacy in Self-Regulation (Barnes et

al., 2008).

In Australia, preliminary findings from case studies indicated that the implementation of the

Alert Program® in classes had increased the amount of time students with sensory processing

issues spend on their academic tasks (Spillane et al., 2011).

Refer to Appendix A for critical appraisal of studies on the Alert Program®.

The Alert Program® is widely used by occupational therapists who work in the schools with

students with self-regulation/sensory processing problems. In the US, 46.8% of school-based

occupational therapists (n=476) used the Alert Program® with students with emotional

28

disturbances (Barnes, Beck, Vogel, Grice, & Murphy, 2003). Since 2010, the Louis Riel School

Division in Manitoba adapted the Alert Program® to develop a model for self-regulation in their

schools (M. Murray, personal communication, January 30, 2012). In September 2012, six school

boards in British Columbia began the first multi-board self-regulation project based on the Alert

Program®(Sully & Stendahl, 2012). As well, several occupational therapists have published

anecdotal evidence supporting the use of this program in schools (Cahill, 2006; Salls & Bucey,

2003; Schoonover, 2002). The Alert Program® is a very common approach that school-based

occupational therapists use to support teachers and students on self-regulation.

Comparing the studies reviewed above, it is unfortunate to note that only one was a Level6 I

study (Wells et al, 2012). Interestingly, that Level I study resembled the most this research since

it adapted the Alert Program®, as was done in this study. The other studies consisted of three

Level III’s and four Level V’s. Although, their level of evidence may be weak, these studies still

contributed to the effectiveness of the Alert Program®. In contrast to this research study, all the

studies that were reviewed focused on the students. No studies using the Alert Program® as an

intervention and looking at the classroom management self-efficacy or the impact on the

occupational role and performance of teachers were found.

Sensorimotor Strategies: Five Methods of the Alert Program®

Strategies teachers tend to use to address disruptive/maladaptive classroom behaviors

include environmental modifications, behavioural methods, curriculum modification,

modifications in delivering the curriculum, as well as sensorimotor strategies (Mulligan, 2001).

The Alert Program® has separated sensorimotor strategies into five methods to facilitate

6 A classification system of levels of evidence (Sackett, 1986)

29

instruction to students (Williams & Shellenberger, 1996). Research has been done on a few

methods they recommend.

A critical appraisal of sensory-based strategies to help self-regulation used in the general

education classroom reviewed 13 studies (Level I, n=2; Level II, n=2; Level IV, n=6; Level V, n=2

and Qualitative, n=1 (Sackett, 1986)) concluded that sensory based interventions implemented

in the classroom improved student attention and performance (Worthen, 2010). Furthermore,

school staff were better able to address student needs to achieve a more optimal level of

arousal by implementing sensory-based strategies in the classroom, which improve students’

ability to stay on task, as well as academic performance .

(1) Put something in your mouth. Chewing gum, a sensory strategy for the mouth, was

found to increase sustained attention in adults. Using the Sustained Attentional Response Task

with young adults (n=20), results indicated an effect size of 0.52 (p<0.001) for sustained

attention. Increased calmness as measured by Analogue Mood Scale indicated increased

perceived alertness and calmness (p<0.003) (Johnson, Muneem, & Miles, 2013). Sustained

attention was also found to be improved while chewing gum as measured by computerized

neuropsychological assessment of attention deficits in adults (n=58) (Tucha, Mecklinger, Maier,

Hammerl, & Lange, 2004). In children, a study with Grade 3 students (n=86) found a strong

correlation (p<0.004) between chewing gum and performance over time (Tanzer, von Fintel, &

Eikermann, 2009). In contrast, another study (n=64) of cross over design with healthy children

and children with ADHD found that gum chewing may be detrimental to the attention of the

group with ADHD (p=0.047) (Tucha et al., 2010).

30

Preliminary research on the effects of gum chewing and anecdotal evidence suggests that it

can have a positive effect on the ability for students to concentrate.

Breathing patterns can have an effect on physiological states and affect self-regulation. As

studied by many yogis, the use of breathing exercises reduced unpleasant symptoms and

offered more physical and physiological calmness (Sovik, 2000). Students from nine regular

education classes from two elementary schools (n=194) took part in a randomized control trial

on mindfulness which included breathing exercises. This study reported significant results

between the control and experimental group. The experimental group had fewer problems

after intervention as indicated on the Comprehensive Teacher Rating Scale (social skills subtest:

effect size=0.47, p<0.001; attention subtest: effect size=0.49, p<0.001), decrease in anxiety test

scores on the Test Anxiety Scale (effect size=0.39, p <0.007) and increase in selective attention

in Test of Everyday Attention for Children (effect size=0.60, p<0.001) (Napoli, Rock Krech, &

Holley, 2005). On the PEDro Scale, this RCT scored a 5/10 (PEDro, 1999).

In a pre-post pilot study, the use of breath work with children (n=60) was researched with

kindergarten and first graders. As measured by surveys pre and post intervention, breath work

was found to be promising in supporting self-regulation (McGlauflin, 2010). A comparative

study comparing breath patterns in boys (n=7) with disruptive behaviour to those without

disruptive behaviour, found unstable breathing patterns in the boys with disruptive behaviour.

Following the use of relaxation techniques involving breath work, the boys with disruptive

behaviour had more regular breathing patterns as measured by Compumedic’s thoracic and

abdominal Respiratory Inductive Plethysmography (Jensen, 2012).

31

A qualitative study with teachers of Grades 3, 4 and 5 reported positive results on the use of

five minutes a day of breath work. Results were favourable for both staff and students. They

noted a calmer and more relaxed environment despite the state testing (Sessa, 2007).

Overall, research indicated that the use of breathing exercises with students may be

beneficial to improve their ability to self-regulate to attend and focus.

(2) Move. Offering a student an alternative to a regular chair can be considered a

movement strategy since the alternative seat can provide some movement. Early studies of

sensorimotor seating strategies that provide movement to the body were supported by

preliminary research. As reported in Worthen (2010)’s critical appraisal, a randomized control

trial with a group of second graders with attention difficulties (n=61) on use of disc ‘o sit

cushions resulted in improved attention to task as measured by the Behavior Rating Inventory

of Executive Functioning (BRIEF). On the BRIEF, the Behavioral Regulation Index resulted in

statistically significant improvement (effect size=0.229, p<0.05), the Metacognition Index found

significant difference between treatment and control groups (effect size=0.145, p<0.05), and

the Global Executive Composite also had indicated significant difference between treatment

and control group (effect size=0.324, p<0.05) (Pfeiffer, Henry, Miller, & Witherell, 2008). Using

the PEDro scale, this study scored 6/10 (PEDro, 1999).

In a single subject withdrawal design study, four boys with ASD aged 3 years 11 months to 4

years 2 months demonstrated improved in-seat behaviour and engagement when using a

therapy ball as a chair. Momentary real-time sampling was used to find an increase in percent

of intervals of in-seat and engaged behaviour (Schilling & Schwartz, 2004). In a group of 4th and

5th graders (n=8) with a diagnosis of ADHD or having symptoms of ADHD, using a single subject

32

A-B continuous time-series design, the use of therapy balls as chairs resulted in significant

progress. On the Attention-Deficit/Hyperactivity Disorder Test (ADHDT), post-intervention

scores had decreased significantly (p < 0.001). Momentary time sampling was used to measure

in-seat and on-task behaviour. Results indicated that in-seat behaviour progressed from 45% to

94% while seated on the ball and on-task behaviour progressed from 10% to 80% of the time

(Fedewa & Erwin, 2011). In a regular education setting, students aged 7 to 9 (n=18) used

therapy balls and disc ‘o sit cushions as seating options in the classroom. In this pre- and post-

test experimental design, results indicated significant improvements on the Handwriting Speed

Test and the Sensory Profile. On the Sensory Profile School Companion School, results were

reported as significant: Factors 1 (p=0.004), 2 (p=0.004), 3 (p=0.004) and 4 (p=0.008). On the

Handwriting Speed Test, results were also significant (p≤0.0001), as well, word spacing

(p=0.00006), letter formation (p=0.04) and overall handwriting legibility (p=0.005) progressed

significantly when using the alternative seating options. (Auld & Burgman, 2011). In contrast,

one study found mixed results on the use of therapy balls as chairs with children with Autism

Spectrum Disorders (n=6). They used a single-subject design and found that the therapy ball

chair may be appropriate for children seeking out vestibular-proprioceptive input but not for

those with postural issues (Bagatell, Mirigliani, Patterson, Reyes, & Test, 2010).

Results of several studies indicate that the use of alternative seating may be used in regular

education classrooms to help students improve behaviour, attention, and self-regulation.

Movement of the body, such as exercise, has been used as a sensorimotor strategy to impact

behaviour and self-regulation. The use of regular physical activity for students (n=21) aged 7 to

12 years with ADHD was supported. Impulsivity (p=0.035), anxiety depression (p=0.01), and

33

social issues (p=0.05) as measured by the Child Behavior Checklist decreased after participating

in ten weeks of 45 minutes of physical activity three times a week. On the Test of Everyday

Attention for Children, sustained auditory attention was significantly improved (p=0.03) (Verret,

2012).

A qualitative study design using focus groups with third grade students (n=21) in a low socio-

economic neighborhood, indicated that eight weekly yoga sessions were beneficial for the

students. Three themes emerged from the focus groups: 1) feeling calm and focused, 2)

controlling their own behaviour and 3) supporting a positive self-esteem (Case Smith, Shupe

Sines, & Klatt, 2010). More recently, a cohort study with pre- and post-test design, with

elementary school students (n=51) 5 to 9 years old receiving special education services

indicated that the implementation of Get Ready to Learn7 improved four key classroom

behaviours. The Get Ready to Learn Supplemental Data Sheet measured statistically significant

progress on level of independence (p<0.000), attention (p<0.000), transition (p<0.000), and

self-regulation (p<0.000) (Garg et al., 2013).

Anecdotal evidence on the use of proprioceptive input to calm and modulate sensory

systems was used frequently by occupational therapists (Blanche & Schaaf, 2001). A single

subject study design with boys (n=3) with ADHD and sensory processing issues used five

minutes of proprioceptive exercises done twice daily. These were done with the whole class

and proprioceptive exercises resulted in decreased duration of aggression for two of the three

boys (p=0.02, p=0.002) and decreased number of aggressive acts for one (p=0.035). Qualitative

data was gathered from the teacher. She reported that the use of proprioceptive exercises had

7 A program using yoga postures, relaxation, chanting, and breath work to enhance the functional and academic performance of students (Garg et al., 2013)

34

a profound effect on her whole class, including less arguing amongst students (Lopez & Swinth,

2008).

Overall, studies on using movement with children indicated that their attention and

behaviour were impacted positively.

(3) Listen. In a randomized control trial as reported in Worthen (2010)’s critical appraisal,

calm music was used in the background with 10-12 year olds (n=31). In this study, task

performance, as measured with mathematical problems, improved significantly (p=0.02)

(Hallam, Price, & Katsarou, 2002). The authors noted that calm music was more conducive to

positive changes than arousing, aggressive music. This RCT scored 5/10 on the PEDro Scale

(PEDro, 1999).

Another recent study with mixed methods multiple single subject design provided evidence

that the frequency and stability of attending and engaging behaviours in the classroom were

improved once sound absorbing walls and halogen lighting8 were installed (Kinnealey et al.,

2012). Students (n=4) with severe communication disorders, including ASD, aged 13-20

reported improved performance in their ability to concentrate. Results on the Sensory Profile

indicated that three of these students exhibited sensory issues related to sound. Attending and

non-attending behaviours were recorded using videotaping and journaling by the students was

used for data collection. All four students had a decrease in frequency of non-attending

behaviours and journaling responses reported more focus on tasks in a quiet room (Kinnealey

et al., 2012). This study provided preliminary evidence that decreasing auditory distractions can

impact attention and behaviour.

8 Halogen lighting replaced the fluorescent lights which emitted a low-level buzz.

35

The use of noise reduction headphones was effective in a single case study with an 11 year

old boy with ASD attending regular education. Time on task was recorded through observation

and visual analysis of results indicated that increased levels of attention was present in all

intervention phases of the study (Rowe, Candler, & Neville, 2011).

Documented evidence for providing auditory input such as calm music or decreasing noise

level supports the use of auditory strategies as recommended by the Alert Program®.

(4) Look. The use of providing visual activity schedules to students (n=4) with ASD, high

functioning, was studied in a single subject A-B-A-B withdrawal design with children aged 7.4 to

8.11. Results indicated an increase in on-task and on-schedule behaviours as measured by

observation. Students’ mean performance of on-task behaviours was low (range 5-31.5%) and

improved to increases in performance to 100% for three students and to 99.5% for the other.

For on-schedule behaviours, their mean pretest performance was low (range 3.3- 21.5%) and

increased 100% posttest (Bryan & Gast, 2000).

Many other studies have reported the use of picture schedules to improve the teaching

environment of students with special needs (Schopler, Mesibov, & Hearsey, 1995).

Hence, in addition to adding visual supports, the use of visual schedules can help students

focus and attend to the task at hand.

(5) Touch. In a randomized control trial with children (n=46) less than 6 years old receiving

autism services, qigong massage9 was reported to improve sensory impairment significantly on

the Self-Regulation Checklist (SSC) (effect size=0.346; p<0.002). As well, teachers blind to group

assignment reported significant improvements in autistic behaviour and social and language

9 A protocol consisting of applying patting, shaking and pressure movements on the body (Silva, Schalock, & Gabrielsen, 2011)

36

skills in the treatment group. The correlation between the change scores on the SSC and

behavioural changes was 0.819 (p<0.0001) (Silva, Schalock, Ayres, Bunse, & Budden, 2009). This

RCT scored an 7/10 on the PEDro Scale (PEDro, 1999).

Children (n=12) diagnosed with ASD aged 4 to 13 years were randomly assigned to an

experimental or a placebo group which looked at using deep pressure on the Hug Machine10.

Results of an initial correlation analysis prior to intervention indicated that there was a

correlation between the behavioural indexes and the physiological indexes of anxiety and

arousal (r ranged from 0.46 to 0.65). Children with increased baseline anxiety benefitted the

most from deep pressure as measured by galvanic skin response. Following 12 weeks of

intervention, decreased tension was noted on the Conners Parent Rating Scale in the

experimental group (p<0.01) (Edelson et al., 1999).

Touch was studied among preschoolers (n=22; average age 4.5 years) who were randomly

assigned to an experimental or a control group. Results indicated that those in the

experimental group improved on the Early Social Communication Scales for joint attention

(p<0.05), behaviour regulation (p<0.01), social behaviour ( p<0.01), and initiating behaviour

(p<0.01). On the Autism Rating Scale, they also progressed on the sensory scale (p<0.05),

relating scale (p<0.05), and the total scale score (p<0.05). It was also noted that they did better

with a decrease of behaviour of orienting to irrelevant sounds (p<0.05) (Field et al., 1997) . This

RCT scored 6/10 on the PEDro Scale (PEDro, 1999).

10 A device constructed of two padded side boards that are hinged together at the bottom to form a V. The person lies between the two boards and can regulate the pressure exerted by the boards (Edelson, Edelson, Kerr, & Grandin, 1999)

37

Fidgeting with an object was found effective in a study with 9 year olds (n=4) with

undiagnosed attention issues. Results indicated that all four students completed more math

problems with intervention; two of the four students had more correct math problems with

intervention than without. Their percentage of time on off task behaviour decreased with

intervention (38% vs 21%, 35% vs 14%, 39% vs 21% and 28% vs 21%) (Kercood, Grskovic, Lee, &

Emmert, 2007).

Weighted vests, which provide deep pressure, have been found effective in a quasi-

experimental, single-system AB design in students (n=4) with sensory issues. All students

increased their on-task behaviour: 54% to 79%, 63% to 81%, 64% to 82%, and 64% to 81%

(VandenBerg, 2001). However, a more recent study with an intervention (n=7) and a control

group (n=4) using an ABA design, indicated that the weighted vests were not effective in

increasing time on task (Collins & Dworkin, 2011).

Suggested as one of the five methods of the Alert Program® to self-regulate, touch or tactile

input research shows its promise as a way to impact attention to task and improve behaviour.

The use of sensory strategies with the mouth, the movement, the ears, the eyes, and the

tactile system, as noted above, are reported to have a positive impact on behaviour and self-

regulation. The empirical evidence in the use of sensory strategies to improve self-regulation is

sparse and still emerging. Adjusting the environment or providing students with specific

sensory strategies/experiences to support their self-regulation in the classroom remains an

intervention of interest among classroom teachers.

Refer to Appendix B for critical appraisal on studies with sensory strategies.

38

Of the twenty-three studies reviewed on various sensorimotor strategies, five are Level I

studies. These five heavily supported the evidence of using deep pressure touch, music, breath,

and Disc’O Sits with children to improve attention, engagement or focus. These studies justified

the use of each of these sensory tools used in this research study. Although the studies on the

use of therapy balls as alternative seating did not have the same level of evidence (Level II, n=1

and Level IV, n=3) (Sackett, 1986), they were used in this study since results were more

supportive than not. Levels of evidence for the use of gum as a sensorimotor strategy were also

not as strong as for the use of deep pressure or movement; however, gum was used as an

option for a sensorimotor strategy in class since it is more socially acceptable than chewing

one’s clothing or hair.

In contrast to this research study, all the studies reviewed on the five categories of the Alert

Program® did not look at the impact on teachers. However, the research supported the use of

strategies effective for the self-regulation of students. Now the question is how this research

evidence can help the teacher with classroom management? In this study, the Alert Program®

and sensorimotor strategies was used as tools for the teacher to help with self-regulation in the

classroom, thus impacting classroom management.

Knowledge Translation

It is clearly a challenge to disseminate knowledge AND have the individuals involved in the

learning process apply the knowledge. The literature indicated that the transfer of research to

practice is a slow process which was not always effective (Agency for Health Research and

39

Quality, 2001). Knowledge translation11 is a growing trend in Canada and much research has

been dedicated to evaluating methods for knowledge uptake, particularly with physicians (Law,

Missiuna, & Pollock, 2008).

Using a one day workshop, the more common and traditional approach of continuing

education to disseminate knowledge, can be useful since teachers turn to professional

development resources to improve their skills in the classroom. Empirical data suggested that

lack of training is an important barrier most commonly reported by elementary school teachers

working with students with ADHD (Reid, Vasa, Maag, & Wright, 1994). A study on the disruptive

behaviour of students added evidence for the need for teachers to increase their awareness

and understanding of behaviour difficulties as well as enhance their skills with these students

(Kokkinos, Panayiotou, & Davazoglou, 2004). In addition, training the teacher on how to

respond to the educational needs of children with ADHD was found to effectively reduce

disruptive behaviour in the classroom (Miranda et al., 2002).

Hence, professional development is vital. However, will this be sufficient for successful

knowledge translation? It is important for the theory learned in a workshop context to be

brought back and applied in the classroom. Unfortunately, studies have identified a trend that

shows teachers returning from professional development workshops, implementing a few

changes, followed by a rapid deterioration in implementation (Noell et al., 2005). Research in

knowledge translation indicated that the traditional passive method of disseminating

knowledge through large group educational sessions do not change practitioner behaviours

11 A “dynamic and iterative process that includes the synthesis, dissemination, exchange, and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products, and strengthen the healthcare system” (Canadian Institutes of Health Research, 2012, p. 1)

40

(Grimshaw et al., 2001). It was not enough to provide professional development in the form of

workshops to teachers; training must continue once the professional development is

completed (Rose & Church, 1998). As well, a teacher’s perception of their own skill acquisition

influenced their level of change in habits and methods used in practice (Richardson, 1990). This

change was further supported when interventions are interpersonal and multifaceted

(Armstrong et al., 2013; Gaines, Missiuna, Egan, & McLean, 2008; Grimshaw et al., 2001). How

can it be made more interpersonal?

Not only must the information shared be tailored to the needs of the stakeholders, it must

be valuable enough to instill a desire to change behaviours. Hence, knowledge translation must

be multi-leveled. It must be varied and take on many forms: team work; involves knowledge

users, producers and brokers; strategies and actions; it is not a single activity. Interaction,

collaboration and exchange is a key factor for successful knowledge translation (Davison, 2009).

Therefore, the use of Occupational Performance Coaching (OPC) can be a vital intervention in

the process of knowledge translation. It involves collaboration, exchange and active

engagement on the part of the stakeholder. It explores the barriers and facilitators to goal

attainment.

Since the process of knowledge translation is varied, using a mix of continuing education and

coaching may be more effective to ensure the application of knowledge and facilitate change.

In order to facilitate change in practice, one must look at embedding learning in socially

constructed environments with authentic problems (Thomas et al., 2011). Knowledge imparted

without implementation is less effective and sustainability is decreased. As well, a ‘one-size-fits-

all’ approach to professional development may not be effective in building skills and knowledge

41

since information may not tailored to specific stages of a teacher’s career (Klassen & Chiu,

2010). Change is facilitated with the teacher’s cognition and practical knowledge in addition to

implementing them in the process of what they want to change and how they want it to occur

(Richardson, 1990). OPC will encourage exchange and it will be highly individualized to their

needs, thus fostering change and increasing the success of knowledge translation.

Rationale

It is evident from the literature that the demands on regular education teachers with

students with disruptive and challenging behaviours can be stressful. Inclusive education,

although it has its merits, is not easy for teachers. They must meet the learning needs of all

the diverse students. This demand can impact their occupational role, thus impacting their

occupational performance. Because teachers with an improved occupational performance

and high sense of efficacy are more likely to have higher job satisfaction and perception of

their performance, it is important to support them in their teaching roles (Schultz et al.,

2010).

Although there have been several studies looking at school-based occupational therapy,

the outcome measure was frequently the student’s progress in a certain area rather than the

teachers’ perception of their ability to help the students. Previous recommendations have

been made to identify teachers as the focus for intervention. When given structured support

in the form of a workshop and OPC to use self-regulation strategies with students in the

classroom, their perceived performance can increase which, in turn, may impact their self-

efficacy (McCormick & Barnett, 2011; Mulligan, 2001). As well, OPC is a client and occupation

42

centred structured approach that takes into account adult learning and knowledge uptake

methods.

To date, no known studies were found that specifically addressed the teachers’ perception

of their performance and satisfaction of performance to support students to use self-

regulation strategies in their classroom. In addition, follow-up measures were incorporated in

this study because, although preliminary research supports the use of the Alert Program®, no

known research incorporated re-administering their measures at follow-up to ensure if

progress was maintained.

This current study examined and explored the effectiveness of a one day training workshop

on the use of tools and strategies for enabling the self-regulation of students with

maladaptive behaviours followed by eight OPC sessions in enhancing the perceived

occupational performance of teachers. As well, this study contributed to the growing body of

research on knowledge translation.

43

Chapter 3. Objectives

1. To find the extent which a one day training and eight OPC sessions impacts elementary

school teachers’ perceived performance on the use of tools and strategies for self-regulation of

their students with maladaptive behaviours.

2. To find the extent which a one day training and eight OPC session impacts elementary school

teachers’ perceived satisfaction on the use of tools and strategies for self-regulation of their

students with maladaptive behaviours.

3. To find the extent which a one day training and eight OPC session impacts elementary school

teachers’ self-efficacy regarding classroom management.

4. To measure if change is maintained in teachers’ perceived performance, perceived

satisfaction, and self-efficacy regarding classroom management skills following a seven week

period.

44

Chapter 4. Methods

Monitoring Knowledge Use

Participants

Participants were sought amongst elementary school teachers of the Eastern Townships

School Board (ETSB). The inclusion criterion was elementary school regular classroom teachers.

There were no exclusion criteria. Sampling: The ETSB oversees twenty elementary schools with

a wide territory covering roughly 10,000 km2. It is a large rural English speaking school board in

the south eastern part of the province of Quebec. This school board is representative of rural

English speaking school boards in the country. Hence, participating teachers were similar to a

sampling of teachers from other rural English speaking school boards.

Thirteen teachers responded by email to the primary researcher. Eleven met the inclusion

criteria, two were physical education teachers. Refer to Table 2 for more details on the

participants.

Design

A multiple-case replication design (Yin, 2012) was used for this study. Teachers were defined

as being the cases. Case study research can be used when describing new methods of

intervention or if the research is exploratory (Yin, 2009)

Quantitative data was generated across three time points: (1) 1-2 weeks prior to

intervention, (2) 1 week post intervention and (3) follow-up: 7-8 weeks after post intervention

measures were completed. A diagram of time frame of the overall study is presented in Figure

5.

45

A thematic analysis of the participants’ goals was carried out. Qualitative data was gathered

from open-ended questions during semi-structured interviews and during classroom

observations. This pilot study enabled the exploration of the use of a workshop and OPC to

impact perceived performance, satisfaction of performance, and self-efficacy in teachers in the

use of sensory strategies to support the self-regulation of their students in the classroom.

Outcome Measures

Canadian Occupational Performance Measure. Perceived performance of the teacher

regarding their skills to support self-regulation in the classroom and satisfaction of this

performance was measured using the Canadian Occupational Performance Measure (COPM), a

criterion based, individualized standardized outcome measure designed to detect change in a

client’s self-perception of occupational performance over time (Law et al., 2005). The COPM is

conceptually based on the Canadian Model of Occupational Performance and identifies

occupational performance problems (Townsend, Stanton, & al., 2002). A systematic review

indicates that the measurement properties of the COPM have repeatedly shown that it is

satisfactory to excellent (Carswell et al., 2004). Its’ reliability exceeds 0.84; its’ validity has been

investigated against other measures and has been supported (Law et al., 2005). Research

supported the ecological validity of this measure (Doig, Fleming, Kuipers, & Cornwell, 2010;

Verkerk, Wolf, Louwers, Meester-Delver, & Nollet, 2006).

The COPM begins by a semi-structured interview to identify issues in performance, rate the

importance of the issues and rate performance and satisfaction of performance for each issue

identified. The scores range from one to ten (ten=extremely satisfied) on a visual analog scale; a

46

two point difference between pre and post-intervention have been found to indicate clinically

meaningful change (Law et al., 2005).

The COPM results in two types of self-report scores: performance and satisfaction. Although

the COPM has been divided into three areas (self-care, productivity, and leisure), these provide

structure but can be modified (Law et al., 2005). Hence, in this study, focus was on productivity.

Goal Attainment Scaling. Goal attainment scaling (GAS) was used with the teachers as a

goal-specific measure on identified issues to improve. It is a criterion based measure based on

the premise that there exists no adequate global definition of human goals, instead needs may

be defined according to each client at that particular time (Kiresuk, Smith, & Cardillo, 1994).

GAS is an individualized measure designed to track within participant longitudinal change

(Ottenbacher & Cusick, 1993). It has been used extensively in occupational therapy as an

outcome measure of occupational performance (Cusick, McIntyre, Novak, Lannin, & Lowe,

2006; Doig et al., 2010; Graham et al., 2010; King, McDougall, Palisano, Gritzen, & Tucker, 1999;

Miller, Schoen, James, & Schaaf, 2007b; Ostensjo, Oien, & Fallang, 2008; Ottenbacher & Cusick,

1990). Although GAS was developed in 1968, few publications have assessed its psychometrics.

Recommendations were given by several studies that training for GAS was needed to improve

its strength (King et al., 1999; Steenbeek, Ketelaar, Galama, & Gorter, 2007). Evidence of inter-

rater reliability, validity, and sensitivity to change was found (Rockwood et al., 2003). When

carefully implemented, inter-rater reliability on GAS can be high (intraclass correlation

coefficient=0.98) (King et al., 1999). The high sensitivity to change with this measure has also

been reported (Cusick et al., 2006; Sladeczek, Elliott, Kratochwill, & Robertson-Mjaanes, 2001;

Steenbeek et al., 2007).

47

Individual goals of participants were scaled from -2 to + 2; each participant had their own

outcome measure which is scored in a standardized way to allow statistical analysis (Cardillo &

Choate, 1994; Turner Stokes, 2009). In this case, the -2 level accounted for no change occurring

since it included the current level of performance. Each goal is rated on a five point scale: 0

(zero) is the expected level of performance, if they achieve more than the expected outcome

this is scored +1 (somewhat more) or +2 (much more); if they achieve less than the expected

outcome this is scored at – 1 (somewhat less) or -2 (much less) (Bovend'eerdt, Botell, & Wade,

2009; Mailloux et al., 2007; Turner Stokes, 2009). Should the performance level regress, a -3

level will be added (May Benson, 2013).

Once the goals (level 0) were established with the participant, the primary researcher set the

scales to be relevant, understandable, measurable, behavioural, attainable, and time limited

(Bovend'eerdt et al., 2009; Ottenbacher & Cusick, 1990). With GAS, bias can result from how

the goal is written, each scale must only reflect a single dimension of change and each interval

between the levels must be as equal as possible (Steenbeek, Ketelaar, Galama, & Gorter, 2008).

To ensure that the GAS goals were written according to guidelines, the scales were reviewed by

a therapist with GAS experience.

To determine whether change was significant, T-score is calculated for GAS. Kiresuk and

Sherman (1968) formula’s for the calculation of the T-score is as follows:

T = 50 + (10∑𝑤𝑖𝑥𝑖)/ �(1 − 𝜌)∑𝑤𝑖2 + 𝜌(∑𝑤𝑖)2

where xi represents the outcome score for each goal (value between -2 and +2) and wi

represents the weight assigned to that specific goal. In this case, each GAS goal was set with

equal weight. The 𝜌 value reflects the estimated intercorrelation between outcome scores

48

which can be assumed to be 0.30 (Cardillo & Smith, 1994; Kiresuk & Sherman, 1968). GAS has a

mean of 50 and a standard deviation of 10 (Cardillo & Smith, 1994). T scores of 50 indicate

expected levels of performance; T scores above and below 50 indicate above and below-

expected levels of performance. Hence, a T-score of ≥ 50 indicates a clinically significant change

(Doig et al., 2010).

Both the COPM and the GAS offer ecological validity since they measure meaningful real-life

performance (Doig et al., 2010).

Teachers’ Sense of Efficacy Scale-Classroom Management. The self-efficacy construct was

measured with the Teachers’ Sense of Efficacy Scale Classroom Management Factor (TSES-CM)

(Appendix C) developed by Tschannen-Moran and Woolfolk Hoy (2001). It is a questionnaire

with eight questions and it has a reliability coefficient of 0.90. A review of classroom

management self-efficacy scales, states that this measure has good factor structure and

stability (O’Neill & Stephenson, 2011). The intraclass correlation for the classroom management

subscale had a value of 0.99 (95% CI=0.98 to 0.99) (Tsigilis, Koustelios, & Grammatikopoulos,

2010). The TSES was the preferred measure for investigating teachers’ self-efficacy (Heneman,

Kimball, & Milanowski, 2006). Although this scale uses a Likert scale rather than a visual analog

scale, studies report that there is no conclusive evidence that one is superior to another

statistically (Couper, Tourangeau, & Conrad, 2006; Guyatt, Townsend, Berman, & Keller, 1987;

Hasson & Arnetz, 2005). Since this is a questionnaire, self-report bias can occur due to social

desirability but the TSES is self-administered so bias may be reduced (Nederhof, 1985). Since

the authors did not report a norm referenced clinically meaningful change (M. Tschannen-

Moran, personal communication, November 14, 2012) to determine clinically meaningful

49

change on the TSES subtest, a reliable change index was calculated (Jacobson, Follette, &

Revenstorf, 1984; Jacobson & Truax, 1991) This reliable index change, amended by Christensen

and Mendoza (1986) and used by Jacobson and Truax (1991) can be calculated as follows:

RC= x2 – x1

Sdiff

where x1 is the participant’s pretest score, x2 is the same participant’s post test score, and Sdiff is

the standard error of difference between the two test scores. Sdiff can be calculated directly

from the standard error of measurement SE according to this:

Sdiff =�2(SE)2

Sdiff refers to the spread of the distribution of changes scores that would be expected if change

occurs. s1 is the standard deviation of the measure.

SE = s1�1 − 𝑟𝑒𝑙𝑖𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑚𝑒𝑎𝑠𝑢𝑟𝑒

A reliable change index larger than 1.96 would be unlikely to occur (p < 0.05) without actual

change (Jacobson & Truax, 1991).

In the Classroom Management subscale, the reliability of measure is 0.90, the mean is 6.7

and standard deviation is 1.1 (Tschannen-Moran & Woolfolk Hoy, 2001). A reliable change

index was calculated for each participant (refer to Appendix D for sample calculation).

Process of Implementation Measures

Child Behavior Checklist for ages 6-18: Teacher’s Report Form. Achenbach’s Child Behavior

Checklist for ages 6-18 is completed by parents or caregivers to provide information regarding

children's competencies and behavioral/emotional problems. It has a teacher form to obtain

information specifically on behaviours at school. The Teacher’s Report Form is modelled on the

50

Child Behaviour Checklist for Ages 4-18 (CBCL/4-18) and is designed to obtain teachers’ reports

of their students’ adaptive functioning and problems in a standardized format (Achenbach,

1991). The Teacher’s Report Form (TRF) from the CBCL was used as a guideline to gather

information regarding overall student behaviours in the classroom; it was not used for

individual students. This measure was not scored. It was used as a guide for observations.

The TRF’s test retest reliability was found to be high over a mean interval of 15 days with a

mean of r=0.90 for academic and adaptive scores and 0.92 for problem scores. Inter-rater

reliability was r=0.55 for academic and adaptive scores and r=0.54 for problem scores.

Construct validity using the closest counterpart of the TRF, Aggressive Behaviour and

Externalizing, against the Conners Hyperactivity Index indicates r=0.67 and r=0.63 respectively.

The total problems score was the closest counterpart to the Conners Hyperactivity Index with

r=0.71 (Achenbach, 1991).

Semi-structured interview. At the end of intervention (post), and eight weeks after

intervention has ended (follow-up), a debriefing interview was conducted to gather the

participants’ experiences with the program. The questions (Appendix E) were asked in a semi-

structured nature; this provided a framework and allowed for some flexibility to gain more

information about supporting self-regulation and strategies they are using in their classroom

(Silverman, 2005).

Fidelity Measure. Fidelity measures ensure that the intervention is applied as was intended

(Di Rezze, Law, Willem Gorter, Eva, & Pollock, 2012). The OPC Stroke Fidelity Checklist (Kessler,

2013) was created as a tool to be used in a randomized control trial to provide feedback to the

treating therapist (D. Kessler, personal communication, February 13, 2013). In this study the

51

OPC Stroke Fidelity Checklist12, was self-administered by the principal investigator after every

OPC session (Appendix F). As well, consultations with Dr. Fiona Graham were done every two

weekly during the OPC interventions to ensure fidelity to the approach.

Procedures

1. Once consent form (Appendix G) was signed, participants were contacted by the

primary researcher to set up an initial interview to complete the pre-intervention

measures (Appendix H for outline of initial interview). Data on age, years of experience

and other effect modifiers were collected with a questionnaire completed by

participants at this time (Appendix I). Baseline measures were done in a semi-structured

interview using the Canadian Occupational Performance Measure. The Teacher Self-

Efficacy Scale Classroom Management subscale was completed. The initial interview

lasted on average 80 minutes and was audiotaped. Transcriptions were done and

accuracy confirmed by participants. Refer to Figure 5.

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management; OPC: Occupational Performance Coaching

12 Although called the OPC Stroke Fidelity Checklist, it can be used to when working with any population since it is the principles of OPC remain the same regardless of the client population.

Pre-Intervention Intervention Post-Intervention Follow-up

Recruitment and consent

COPM, TSES-CM

Within two weeks of end of intervention

Given within two weeks of initial data collection

Figure 5. Time line of procedures

Completed 7.4 weeks after post-intervention measures

COPM, GAS, TSES-CM completed

COPM, GAS, TSES-CM completed

One day group workshop

Eight individual OPC sessions

+

GAS goals scaled

8-12 weeks

7-8 weeks

52

2. Goal attainment scaling by the primary researcher was done on the issues raised by

each participant. GAS goals were verified by therapists experienced with GAS. The

current level of performance was reflected in the -2 level; thus scoring -2 reflects no

change and regression will be reflected as a -3. Refer to Table 1 for an example of a

COPM issue scaled into GAS levels.

Table 1. Example of issue as noted by the Canadian Occupational Performance Measure and scaled with the Goal Attainment Scale. Canadian Occupational Performance Measure issue

Goal Attainment Scale scaled goal

Transitions from recess back to classroom - 2: Grade two students transition back to class last most of the week. -1: Grade two students transition back to class after the grade 1 students most of the week. 0: Grade two students transition back to class after the grade 3-4 class most of the week. +1: Grade two students transition back to class before the grade 3-4 class most of the week. +2: Grade two students transition back to class before the grade 3-4 class without fussing about what happened at recess most of the week.

3. A one hour classroom observation (Appendix J) took place within one week of the initial

intake in order for the researcher to observe the teacher’s students in class. The Child

Behavior Checklist for ages 6-18: Teacher’s Report Form guided the classroom

observation; the whole class was observed using the checklist to identify and note

specific behaviours (e.g. talks out of turn, inattentive or easily distracted, explosive and

unpredictable behaviour). The aim was to gain information on the global makeup of the

class and observe a snap shot of the daily challenges the teacher was facing.

53

4. Intervention by the primary researcher began within two weeks of collecting pre-

intervention data. The primary researcher taught a one day workshop entitled Tools to

Improve Attention and Self-Regulation for Students in the Classroom. An overview of the

Alert Program® was presented at the workshop. Videos, learning tasks, and discussions

were used as tools to relay the information. Teachers learnt about sensorimotor

strategies they can implement in the classroom. The content and activities of the

workshop was based on experience of the researcher as well as a review of the

literature. (Refer to Appendix K for an outline of workshop, Appendix L for objectives

and learning outcomes, Appendix M for slides from the workshop, and Appendix N for

references from the workshop). The primary researcher, at the time of the study, had

over twenty years of clinical experience working with children, their families and

teachers, including over 10 years consulting in schools.

5. A Workshop Feedback Form (Appendix O) was sent by email to all the participants

regarding the workshop.

6. Following the workshop, the use of OPC was used for all eight of the individual sessions

with the participants (Appendix P for outline of individual sessions). The OPC individual

meetings with the participants were held at each of their schools. All eight OPC sessions

were done in a structured process and lasted 60 minutes. Detailed notes were taken by

the primary researcher. To ensure that the intervention therapist’s method of using OPC

is true to the approach, biweekly consultations with Dr. F. Graham were made. As well,

the use of fidelity measure guidelines (Appendix F) were completed following each OPC

session to ensure that the method of doing OPC is done consistently.

54

7. During the intervention phase, participants had the possibility to initiate contact with

the researcher by telephone or by email one additional time per week should they need

more intervention. Participants had a daily log to fill out to record the sensorimotor

strategies they use with students (Appendix Q). When participants did not have the

tools they required or wished to try in their classroom (e.g. therapy ball chair, music CD,

etc.), the researcher provided them with the tools for the duration of the study.

8. At the end of eight OPC sessions, post-intervention measure interviews lasting 30

minutes were done within one week. As well, a one hour classroom observation done at

the same time and day of the week as the pre-intervention observation.

9. Eight weeks after the post-intervention measures were completed, measures were

repeated and a few debriefing questions were asked in a follow-up interview lasting

approximately 30 minutes (Appendix E). This study is enriched by gathering information

on change following seven weeks after the post-intervention measures have been

completed.

Refer to Figure 5 for an overview of the procedures.

Analysis

This study estimated the extent of change in the perception of performance, performance

satisfaction, and self-efficacy in teachers using self-regulation strategies with their students

following a workshop and eight individual OPC sessions.

The objective indicates that the parameters of interest are change over the intervention

period (pre-intervention to post-intervention) on four outcomes and maintenance of change

from post-intervention to follow-up.

55

Since this was a pilot study with a small sample size, a person based analysis was used. Each

participant’s results on each measure were classified as a responder or a non-responder to the

intervention. A responder was defined as having a clinically meaningful change on an outcome

measure. Statistical analyses were based on a change of 2 points as an indication of response

for the COPM. A response on GAS was determined with T-scores ≥ 50. A response on the TSES-

CM was a reliable change index (RCI) of ≥ 1.96.

Our parameter of interest was the proportion of participants who responded on at least one

measure (subsequently more than 1 or all) over the two time periods. These proportions and

their 95% confidence intervals were estimated.

There was no missing data since all participants were present for 100% of the phases of this

study.

Confidentiality

Every effort was made to ensure confidentiality of any identifying information that was

obtained in connection with this study. Each participant was assigned a number to ensure that

their name not be used in data collecting. Their numbers, not their names, appeared on all

questionnaires they complete. No party other than the primary researcher knew what names

correspond to what number.

Ethical Considerations

The Institutional Review Board of McGill University granted approval of this research project

(Appendix R). The Director’s Committee of the Eastern Townships School Board granted

permission for the research to take place on their territory (Appendix S). Principals of the

56

elementary schools were contacted by email to request permission to contact their teaching

staff (Appendix T) and teachers from nineteen of the twenty schools were contacted (Appendix

U). Participating teachers had the right to ask any questions at any time and their participation

was on a volunteer basis. They could withdraw at any time without penalty. Refer to Appendix

G for consent form.

57

Chapter 5. Results

Eleven elementary school teachers participated, 9 were female (82%) and 2 were male

(18%). 6 (55%) had between 1-5 years of teaching experience, 2 (18%) had between 6-10 years,

2 (18%) had between 11-15 years, and 1 (9%) had more than 16 years of teaching experience.

The teaching experience ranged from 1 to 27 years; the average was 8.1 years. Exceptionally,

one teacher taught two regular education mutli-grade classes; he was in a very small rural

town. Three (27%) had support from an aide in the classroom; only one of these had an aide for

the full amount of time she taught that group. Three (27%) participants had done a previous

workshop (1 hour to 8 hours) on self-regulation in the classroom. The eleven participants came

from nine different elementary schools. Refer to Table 2 for details.

Table 2. Description of the participants Participant/gender Years of

experience Grade taught

Their perception of degree of behaviour issues in class (mild, moderate, severe)

Hours per week of in-class support by aide

Had previous workshops/training on self-regulation

1/F 13 3 & 4 mild-moderate 3 none 2/F 8 2 moderate 11 none 3/F 15 K moderate 0 yes, 2 hours 4/M 3.5 preK-3,

4 to 6 severe 0 no

5/F 1 5 mild 0 no 6/F 6 4 mild-moderate 0 yes, 8 hours 7/F 5 4 & 5 moderate 0 no 8/F 27 K & 1 severe 10.5 yes, 1 hour 9/F 3.5 6 mild-moderate 0 no 10/F 4 3 moderate 0 no 11/M 3 5 moderate 0 no Key: F = female; M = male; K = kindergarten

Overall, this pilot study’s results were positive. Individual results will be presented first

followed by more global results.

58

Outcome Measures

Illustration of each participant. Participant 1 (Figure 6) reported that her class had mild to

moderate behaviour issues. She reached two of her three GAS goals (Appendix V). The unmet

goal pertained to her abilities to help one particular student with organisation and self-

regulation. Since this student had an aide, the teacher did not need to spend as much time with

him and her goal improved to somewhat less than expected outcome. Overall, participant 1

showed clinically significant change on the Canadian Occupational Performance Measure-

Performance (COPM-P), Canadian Occupational Performance Measure- Satisfaction (COPM-S)

and on Goal Attainment Scaling (GAS) at post-intervention. No clinically significant change was

noted on the Teacher Self-Efficacy Scale- Classroom Management (TSES-CM). Even after 16

years of teaching, she reports that she learnt to be more accommodating and understanding to

the needs of the students and that movement is beneficial. She offered more breaks and used a

visual tool (Time Timer™) daily. She allowed her students to use fidgets when needed and saw

the benefit to certain students who can focus better when fiddling with an object. Overall, she

reported being pleased with her progress in occupational performance. As well, she shared that

she was also using sensorimotor strategies with her other class. At follow-up, she was feeling

upset that one particular student was now being homeschooled because his behaviour in

school was becoming too difficult; this may explain the drop in satisfaction and GAS goals. She

scored only two of the three goals at follow-up since one goal pertained to the student who

left. Although they was a slight decrease in the COPM-P, it remained clinically significant when

compared to pre-intervention, unlike her COPM-S result. She reported that she may not have

59

made much progress since the aide in her class was assigned to the students she had decided to

focus on; hence, she was less directly involved.

Figure 6. Results: Participant 1.

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management Note: GAS T-scores were divided by 10 to be plotted with other measures.

Participant 2 (Figure 7) had eight years of teaching experience and considered her class to

have moderate behaviour issues. She reached three of her four GAS goals (Appendix V). The

COPM-P and COMP-S reflected her progress in implementing sensorimotor strategies in the

classroom and improved her abilities in classroom management. Her self-efficacy was improved

clinically significant as noted on the TSES-CM. This participant had particularly challenging

behaviour issues in her classroom and she reported that using heavy work “has been a

blessing.” The bands on the chairs also “saved the day” since the students could fidget their

feet without bothering others. Over all, she reported that her class was calmer, transitions

occurred faster and smoother. In addition, students were using respiration on their own to help

0

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2

3

4

5

6

7

8

9

10

preintervention postintervention follow-up

COPM-P

COPM-S

GAS

TSES

60

cool down as they needed. She felt empowered to use sensorimotor strategies effectively.

Results were not only maintained at follow-up, they had progressed on all measures.

Figure 7. Results: Participant 2.

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management

Note: GAS T-scores were divided by 10 to be plotted with other measures.

Participant 3 (Figure 8), a kindergarten teacher with 15 years of teaching experience and two

hours of training on self-regulation, reached three of her four GAS goals (Appendix V). She

considered her class to have moderate behaviour issues. This participant showed significant

change on the COPM-P and COMP-S measures and verbally reported increased self-efficacy.

Oddly, her TSES-CM did not change from pre- to post-intervention. She was having a

particularly difficult day when post-intervention measures were completed and the TSES-CM

was the first to be completed. It may have been a direct reflection of how she felt at that

moment rather than her overall self-efficacy. Nevertheless, she reported that she learnt to take

difficult students less personally, that she herself was more self-regulated and that she was

more confident with her skills as a teacher. Participant 3 reported that small things like offering

0

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2

3

4

5

6

7

8

9

10

preintervention post intervention follow-up

COPM-P

COPM-S

GAS

TSES-CM

61

a bean bag chair or adding visual boundaries to where students sit during circle time and adding

proprioception/heavy work and breath work to transitioning back to class after recess made a

big difference in student behaviour. She noted a change when sensorimotor strategies were not

used with her kindergarten students, classroom management was more challenging. She

reported that her own self-regulation was very important. When Participant 3 was calm with

the students, she reported feeling better about her performance. Follow-up results were

maintained; they progressed on three measures (Figure 8).

Figure 8. Results:Participant 3.

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management Note: GAS T-scores were divided by 10 to be plotted with other measures.

Participant 4 (Figure 9) reached all three GAS goals and reached them at somewhat more

than expected outcome (Appendix V). These results may have been due to how the goals were

written. However, his scores on the COPM-P, COPM-S and the TSES-CM also indicated

remarkable change. With three and a half years of experience, in a class he considered as one

having severe behaviour issues, this participant was responsible for teaching multi-aged groups.

0

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2

3

4

5

6

7

8

9

10

preintervention postintervention follow-up

COPM-P

COPM-S

GAS

TSES-CM

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Although he had some awareness of sensorimotor tools to help self-regulation, he felt that he

didn’t trust himself to try new things. He stated that with the OPC sessions, he was able to gain

confidence and use the tools effectively. He reported that he was quicker to think about

prevention and self-regulation than giving consequences to ‘bad’ behaviours. Follow-up results

were maintained. The COPM-P decreased slightly but progress remain clinically significant

(Figure 9).

Figure 9. Results: Participant 4.

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management Note: GAS T-scores were divided by 10 to be plotted with other measures.

Participant 5 (Figure 10) had one year of teaching experience and she classified her class as

having mild behaviour issues; she reached all four of her GAS goals (Appendix V). As well, her

scores on the COPM-P, and COPM-S indicated clinically significant progress. Her TSES-CM score

were slightly below being clinically significant. She reported that she used to somehow take the

blame when it wasn’t working for students. Now, she had a better understanding of student

needs and was able to help them self-regulate. She no longer took it personally. For one

0

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4

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6

7

8

9

10

preintervention postintervention follow-up

COPM-P

COPM-S

GAS

TSES-CM

63

particular student, she brought in an ironing board and adjusted it to his height in order for him

to work in standing position. In standing, he was able to complete his work rather than move

constantly when seated and be cued to stay on task. Using fidgets, ball chairs, and allowing

students to chew coffee stirrers was now part of her classroom and she felt satisfied with her

occupational performance. Results of Participant 5 were maintained and they even had

progressed on three measures at follow-up (Figure 10).

Figure 10. Results: Participant 5.

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management Note: GAS T-scores were divided by 10 to be plotted with other measures.

Participant 6 (Figure 11) had the most training with self-regulation prior to this research. She

had attended a one day workshop similar to the one taught as part of the intervention. She

considered that her class had mild to moderate behaviour issues. This participant reached two

of her three GAS goals (Appendix V). Her scores on the COPM-P and COMP-S indicated clinically

significant change. On the TSES-CM she scored slightly below the clinically significant level.

After six year teaching, she states that: “Instead of ignoring behaviours that bothered me, I can

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preintervention postintervention follow-up

COPM-P

COPM-S

GAS

TSES-CM

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deal with them instead.” Despite the prior training, she reported a “mind shift”; her views have

changed because it’s not taken as “bad behaviour but how I can help them with self-

regulation.” Participant 6 reported that this helped with her occupational performance. She

also reported this at follow-up, however, her progress decreased on all four measures (Figure

11).

Figure 11. Results: Participant 6.

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management Note: GAS T-scores were divided by 10 to be plotted with other measures.

Participant 7 (Figure 12) reached all four of her GAS goals (Appendix V), three where scored

at somewhat more than expected level. Again, this may have been to how the goals were

written; however, her scores indicated significant change on the other measures as well:

COPM-P, COPM-S, and the TSES-CM. This participant, with five years teaching experience,

initially reported that she felt like a “sergeant” when she was teaching and she used the

‘incident reports” as a threat with her students. She considered her class to have moderate

behaviour issues. She reported that, with this research study, she stepped out of her comfort

0

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preintervention postintervention follow-up

COPM-P

COPM-S

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TSES-CM

65

zone to try new things with her students. She was no longer taking behaviour issues personally.

Participant 7 reported more self-confidence, more flexibility, and calm when teaching. At

follow-up, progress remained clinically significant and continued to improve on three on the

measures (Figure 12).

Figure 12. Results: Participant 7.

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management Note: GAS T-scores were divided by 10 to be plotted with other measures.

Participant 8 (Figure 13) felt, due to a couple of students, her class had severe behaviour

issues. She reached four of her four GAS goals (Appendix V). She showed change on three of the

four measures: COPM-S, TSES-CM and on her GAS goals. The COPM-P was slightly below the

level required to indicate clinically significant change. This participant reported that following

this study, she had more influence in changing behaviours, even after 27 years of experience.

She reported that “this has been a helpful journey.” Her satisfaction with implementing new

strategies in her grade one class was so high that she also used them in her other class.

Although she stated that she “was out of her comfort zone,” she was open to continue trying

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preintervention postintervention follow-up

COPM-P

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new strategies and problem solving using OPC. At follow-up, progress was maintained on GAS

goals and the TSES-CM but decreased on COPM-P and COPM-S. Although the COPM-S

decreased, her results remained clinically significant as compared to results pre-intervention

(Figure 13).

Figure 13. Results: Participant 8.

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management Note: GAS T-scores were divided by 10 to be plotted with other measures.

Participant 9 (Figure 14) met three of her four GAS goals (Appendix V). This participant

showed change on the COPM-S, TSES-CM and on her GAS goals. Her COPM-P score did not

indicate change although verbally she reported she felt better about herself as a teacher.

Initially, because of the behaviour issues in her class, which she considered mild to moderate,

she reported that she would go home and wanted to cry and could not detach herself

emotionally from her work. At the post-intervention interview, she reported that she was more

confident and learnt to trust her instincts and observations. She felt that the use of the Time

Timer® was a simple tool that made a huge difference in how many times she had to repeat the

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preintervention postintervention follow-up

COPM-P

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same thing during transitions. This participant had three and a half years teaching experience.

She reported that she felt better at problem solving about behaviour and could find solutions.

At follow-up, results were not only maintained on all measures but had continued to improve

on three of the measures (Figure 14).

Figure 14. Results: Participant 9.

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management Note: GAS T-scores were divided by 10 to be plotted with other measures.

Participant 10 (Figure 15) had four years teaching experience and classified her class as

having moderate behaviour issues. She met three of her four GAS goals (Appendix V). Her

scores indicated clinically significant progress on the COPM-P, TSES-CM and on her GAS goals.

She was slightly below the significant change score on the COPM-S. However, verbally she

reported that she felt good about her progress. She reported that she has the capabilities to

better respond to the behaviour needs of her students. She felt that she understood them

better and had confidence in classroom management skills. Before, she was taking it more

personally and felt frustrated. She reported that she no longer felt frustrated and that her

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preintervention postintervention follow-up

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teaching was more fluid, less challenging. She stated that she could focus on teaching rather

than on managing behaviour. In addition, she reported that she now understood how to use

sensorimotor tools. Before participating in this study, she had the tools but was never sure of

what to do with them and who should be using them. At follow-up, progress was maintained

and continued improvement was noted on the COPM-S (Figure 15).

Figure 15. Results: Participant 10

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management Note: GAS T-scores were divided by 10 to be plotted with other measures.

Participant 11 (Figure 16) was a teacher with four years teaching experience and he

considered his class to have moderate behaviour issues. He met all four of his GAS goals

(Appendix V). This participant showed significant progress on all four measures: COPM-P,

COPM- S, TSES-CM and on his GAS goals. He reported that he learnt to be more reflective about

behaviours: “I’m gaining more patience with myself to get it [self-regulation] and that it’s

progressing.” He was able to incorporate movement breaks into the class schedule; he reports

that transitions became easier and less time was “wasted” repeating to get the students’

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attention. Clinically significant changes were maintained at follow-up and continued progress

with COPM-S was noted (Figure 16).

Figure 16. Results: Participant 11

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale-Classroom Management Note: GAS T-scores were divided by 10 to be plotted with other measures.

Looking at results from each participant, progress in both occupational performance and

satisfaction does not appear to be influenced by the number of years of teaching experience.

Both the participants with the most experience and the least experience progressed

significantly on three measures. Interestingly, the majority of participants who scored

significantly on the GAS also showed clinically significant progress on both the COPM-P and

COPM-S. A change also occurred in how participants viewed challenging student behaviour; five

of the eleven participants mentioned that they were no longer taking behaviour issues of their

students personally. They said that they now had a better understanding of the difficulties of

the students and were able to support them more successfully. In addition, participants

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preintervention postintervention follow-up

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reported being able to use the problem solving process in other situations not addressed in this

study.

Overall Results

Objective 1. To find the extent which a one day training and eight OPC sessions impacts

elementary school teachers’ perceived performance on the use of tools and strategies for self-

regulation of their students with maladaptive behaviours. Results indicate that 9 of 11 (82%)

participants reported clinically significant improvement with their perceived performance on

issues they identified that hindered classroom management as measured with the COPM-P on

pre-post-intervention measures (Table 3).

At follow up, done on average at 7.4 weeks after the completion of post intervention

measures, progress was maintained for performance as noted on the COPM-P (Table 3).

Table 3. Results of COPM-Performance and COPM-Satisfaction participant COPM-Performance

Pre post-intervention follow-up COPM-Satisfaction Pre post-intervention follow-up

1 4.3 6.4 6.0 5.0 8.3 6.0 2 5.9 8.8 9.2 6.6 8.6 9.3 3 3.6 6.4 7.0 3.0 6.6 6.8 4 6.1 9.0 8.8 6.1 9.5 9.6 5 5.5 8.0 8.5 5.4 8.8 9.5 6 6.0 8.0 7.0 5.5 8.0 6.3 7 4.6 8.7 9.0 4.2 9.0 9.2 8 6.4 8.2 7.5 5.3 8.3 7.5 9 6.3 7.4 7.8 5.0 7.8 7.9 10 6.3 8.6 8.7 6.8 8.6 9.3 11 2.6 6.5 6.3 2.8 6.3 4.8

KEY: COPM: Canadian Occupational Performance Measure Note: change scores of 2 or more points are considered clinically significant (Law et al., 2005).

Objective 2. To find the extent which a one day training and eight OPC session impacts

elementary school teachers’ perceived satisfaction on the use of tools and strategies for self-

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regulation of their students with maladaptive behaviours. Results indicate that 10 on 11 (91%)

participants reported a clinically significant change their perceived satisfaction of issues

pertaining to classroom management as measured with the COPM-S (Table 5). Participant 10,

who scored slightly below the clinically significant mark, reported that she is continuously trying

to do better and has difficulty ever feeling fully satisfied; “it takes her awhile” she reported.

At follow up, done on average at 7.4 weeks after the completion of post-intervention

measures, progress was maintained on the COPM-S for all but Participant 1. Numbers may

indicate a decrease in score in four participants but only one had a clinically significant change

(Table 5). For Participant 1, one of the students on which she had set a GAS goal was now being

homeschooled so she was feeling dissatisfied that he was unable to remain in school.

Participant 10, who at post-intervention did not show clinically significant change, reported that

she was quite pleased with how far she’d come and was able to continue with the tools and

strategies even without support. “It saved my life,” she said, and “it really helped my teaching

skills.” Her results at follow-up indicate a clinically significant satisfaction of her performance.

Objective 3. To find the extent which a one day training and eight OPC session impacts

elementary school teachers’ self-efficacy regarding classroom management. Of the 11

participants, 8 (73%) were positive responders on the TSES-CM subscale at post-intervention

(Table 6).

The TSES-CM indicated that clinically significant change was maintained from post-

intervention to follow-up measures taken 7.4 weeks after post-intervention measures were

completed. Participant 6 and 11’s results decreased but their progress remained clinically

significant when compared to their pre-intervention score. For 6 of the 11 (55%) participants,

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their reliable change increased indicating further progress on self-efficacy. For 3 of the 11 (27%)

participants, their reliable change index remained the same and 2 (18%) participants’ reliable

change index decreased but remained clinically significant at follow-up (Table 4).

Table 4. Results of Teacher’s Self-Efficacy Scale-Classroom Management participant Pre-intervention Post-intervention (RCI) Follow-up (RCI –follow-

up compared to post to verify if reliable change occurred)

1 7.3 7.9 (1.22) 7.9 (0.00) 2 7.0 8.3 (2.65) 8.6 (0.61) 3 5.9 5.9 (0.00) 6.5 (1.22) 4 7.0 8.0 (2.04) 8.1 (0.20) 5 6.5 7.4 (1.84) 8.3 (1.84) 6 6.6 7.4 (1.63) 7.1 (-0.61) 7 5.4 7.6 (4.49) 8.4 (1.63) 8 6.5 7.5 (2.04) 7.5 (0.00) 9 6.6 7.8 (2.49) 7.8 (0.00) 10 6.9 8.5 (3.27) 8.6 (0.20) 11 3.9 5.9 (4.08) 5.0 (-1.83)

KEY: RCI: Reliable Change Index Note: RCI is clinically significant when ≥1.96

Results of Goal Attainment Scaling. Looking at goals scaled with GAS, 9 of the 11 (82%)

participants had clinically significant results. Overall, 32 of the 41 (78%) goals were met at post-

intervention. Using Goal Attaining Scaling, of the 32 attained goals, 16 were attained at the

expected level, 14 were attained at the somewhat better than expected level and four were

attained at the much more than expected level (Table 5). Level -2 included the current level of

performance. Had regression occurred, a – 3 level would have been used. An example of a

participant’s goal can be found in Table 6.

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Table 5. Results of Goal Attainment Scaling Participant Goals (post-intervention score,

follow-up score) Post-intervention score

Follow-up score

1 Goal 1 = 0, did not score Goal 2 = +1, 0 Goal 3 = -1, -1

50.00 46.37

2 Goal 1 = 0, +1 Goal 2 = 0, 0 Goal 3 = 0, 0 Goal 4 = -1, 0

46.37 53.63

3 Goal 1 = +1, +1 Goal 2 = -1, 0 Goal 3 = 0, 0 Goal 4 = +1, 0

53.63 53.63

4 Goal 1 = +2, +2 Goal 2 = +2, +2 Goal 3 = -1,-1

63.69 63.69

5 Goal 1 = +1, +2 Goal 2 = 0, 0 Goal 3 = +2, +2 Goal 4 = +1, 0

64.51 64.51

6 Goal 1 = +1, 0 Goal 2 = -1, -1 Goal 3 = 0, 0

50.00 45.44

7 Goal 1 = 0, +1 Goal 2 = +1, 0 Goal 3 = +1, +1 Goal 4 = +1, +1

60.88 60.88

8 Goal 1 = +1, +1 Goal 2 = 0, 0 Goal 3 = +1, 0 Goal 4 = +1, +2

60.88 60.88

9 Goal 1 = 0, 0 Goal 2 = 0, +1 Goal 3 = -1, 0 Goal 4 = 0, 0

46.37 53.63

10 Goal 1 = -1, +1 Goal 2 = +2, +1 Goal 3 = -1, -1 Goal 4 = +1, +1

57.25 57.25

11 Goal 1 = +1, +1 Goal 2 = 0, +1 Goal 3 = 0, +1 Goal 4 = 0, 0

53.63 60.88

KEY: - 2: much less than expected outcome; -1: somewhat less than expected outcome; 0: expected outcome; -1: somewhat more than expected outcome; +2: much more than expected outcome Note: T ≥ 50 is clinically significant

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Table 6. Example of a Goal Attainment Scale goal GAS levels Description Much less than expected outcome (-2)

Most students transition back to calm and ready to receive instructions within 5 + minutes of the end of break with 3-4 prompts most of the time.

Somewhat less than expected outcome (-1)

Most students transition back to calm and ready to receive instructions within 3-4 minutes of the end of break with 3-4 prompts most of the time.

Expected level (0) Most students transition back to calm and ready to receive instructions within 1-2 minutes of the end of break with 3-4 prompts most of the time.

Somewhat more than expected level (+1)

Most students transition back to calm and ready to receive instructions within 1-2 minutes of the end of break with 1-2 prompts most of the time.

Much more than expected level (+2)

Most students transition back to calm and ready to receive instructions within 1-2 minutes of the end of break with no extra prompts most of the time.

KEY: GAS: Goal Attainment Scaling

The themes of the individualized GAS goals were transitions (e.g. between classes, between

recess and class) attention and engagement of students, emotional regulation and self-

regulation for specific students (Table 7). Slightly more than half (54%) of GAS goals were

pertaining to specific students; the remainder pertained to the whole class (36%) and specific to

the participant’s skill (10%).

Table 7. Themes of Goal Attainment Scale goals Themes number of goals related to this theme (on 41 total goals) Transitions (ex: from recess back to class, from physical education back to academic work)

7

Student specific on self-regulation 22 Attention and engagement of whole class

11

Emotional self-regulation of whole class

1

Key: GAS: Goal Attainment Scaling

Of the GAS goals pertaining to specific students, 82% of these were attained. At follow-up,

87% of the GAS goals pertaining to specific students were attained. Of the whole class GAS

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goals, 80% were attained. At follow-up, 93% were attained. For those specific to the teacher’s

skills, 75% were attained and the same at follow-up.

Four of the seven goals that were rated somewhat less than expected outcome pertained to

individual students. Perhaps these students required a different approach than the use of self-

regulation strategies. They did show progress, moving from a -2 to a -1 level, however, they did

not reach expected level. One particular student had a diagnosis of ADHD; in his case, the use of

self-regulation strategies without pharmacological, cognitive, or other approaches was not

sufficient.

Looking at the GAS results as a group, results indicated that the group score is T = 55. At T ≥

50, the results are clinically significant; therefore, the overall GAS results were clinically

significant. At follow-up, results indicated that the group score was T = 56. Hence, the group

results continued to be clinically significant 7.4 weeks after completion of post-intervention

measures. Progress was maintained.

Responders vs nonresponders. The use of a one day training paired with eight sessions of

OPC to coach teachers to improve their occupational performance indicated that 10 out of 11

(91%) participants reported clinically significant change on 3 of the 4 outcomes. All participants

(100%) reported clinically significant change on 2 of the 4 outcomes (Table 8).

Each participant’s results on each measure were classified as a responder or a non-

responder to the intervention. A responder was defined as having a clinically meaningful

change on an outcome measure. In this case, results indicated 35 responders out of 44. At a

95% CI, the range is from 0.58 to 0.85 with a probability of response of 0.77 (Generalized

Estimating Equations was used with SAS software). The effect size of this study was 0.58.

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Table 8. Results of responders vs non-responders at post-intervention participants COPM-

Performance COPM-Satisfaction

GAS TSES-CM

1 R R R NR 2 R R NR R 3 R R R NR 4 R R R R 5 R R R NR 6 R R R NR 7 R R R R 8 NR R R R 9 NR R NR R 10 R NR R R 11 R R R R R = 9/11 R = 10/11 R = 9/11 R = 7/11

KEY: COPM: Canadian Occupational Performance Measure; GAS: Goal Attainment Scaling; TSES-CM: Teacher’s Self-Efficacy Scale- Classroom Management; R=responder; NR=nonresponder. Note: In order to be a responder on the COPM a change of 2 is required. For the TSES-CM, the Reliable Change Index must be >1.96 to be a responder. For GAS, T ≥ 50 to be a responder.

Overall average change pre to post-intervention. The overall average change for

performance as measured by the COPM-P was 2.8 and 3.1 for satisfaction on the COPM-S. The

average reliable change index was 2.6 on the TSES-CM (Table 9).

Table 9. Average and standard deviation of overall results on COPM-P. COPM-S, and TSES-CM Change from pre to postintervention

KEY: COPM: Canadian Occupational Performance Measure; TSES-CM: Teacher’s Self-Efficacy Scale- Classroom Management Note: In order to be a responder on the COPM a change of 2 is required. For the TSES-CM, the Reliable Change Index must be >1.96 to be a responder

The eight OPC sessions took place over an average of 11.3 weeks. Ideally, sessions were

done weekly but school cancellations due to snow storms, teachers being sick or pedagogical

Measurement Average (Standard deviation) COPM-P 2.8 (0.88) COPM-S 3.1 (0.83) TSES-CM 2.6 (1.4)

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days necessitated a longer gap between sessions. Time between OPC sessions never exceeded

12 days.

Results of Process

Results of workshop feedback forms. Workshop Feedback Forms on a scale of 5 (5 =

strongly agree; 4 = agree; 3 = no comment; 2 = disagree; 1 = strongly disagree) were completed

by the participants. Results indicate that 8 of the participants would recommend the workshop

to others as rated 5/5 (100%) and the remaining 3 participants rated this as 4/5 (80%). Learning

objectives were met 5/5 (100%) for 8 participants and 4/5 (80%) for 3 participants. All of the 11

(100%) participants reported that they felt able to implement the information from the

workshop into their classroom setting.

Results of classroom observations. The classroom observations were done to get a better

understanding of what issues the participants were dealing with. They lasted one hour pre and

post intervention and were done at the same time of day and same day of the week in order to

observe the students doing the same or similar task. Overall observations pre-intervention

indicated the presence of behaviours based on the Child Behaviour Checklist -Teacher’s Report

Form (Appendix C5) such as: hums or makes other loud noises, can’t concentrate/pay attention

for long, can’t sit still, restless, or hyperactive, fidgets, demands a lot of attention, impulsive or

acts without thinking, disrupts class discipline, showing off or clowning, talks out of turn, and

unusually loud. Teachers were noted to use verbal reprimand, countdowns, and repeat

“shhhh”. Four teachers used threats such as staying in for recess, getting sent to the hallway, or

receiving an incident report.

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Post-intervention classroom observations were completed on average 13.7 weeks following

the first observation. It was noted that the number of behaviours checked off initially had

decreased substantially. As well, teachers were noted to be calmer and repeated much less.

The use of “shhh” to ask students to quiet down was also decreased. In particular, two teachers

were much more confident and this was reflected in their interactions with students. Although

some teachers had been using therapy ball chairs prior to intervention, the variety of strategies

and the availability of the strategies in the classes increased. Time Timer®s, noise reducing

headphones, bands on chair legs (to provide fidgeting for the feet), fidgets, T-stools as chairs,

and quiet corners were available in the class. In addition, rather than reprimanding their

students, two teachers stopped teaching when their students appeared to fidget more and be

less attentive. Instead, they provided a movement break. Transitions during the classroom

observations were smoother and faster, requiring less teacher intervention.

In general, the issues observed with classroom management and student behaviours

decreased from pre to post-intervention.

Results of the daily logs. The participants used a variety of sensorimotor strategies to

support self-regulation in the classroom. Each participant filled out a daily log to report on what

they did (Appendix C7). In the MOUTH category, the use of breath work was considered an oral

motor strategy and it was the most commonly used strategy; 9 of the 11 (82%) participants

used breath work during class to help students self-regulate. Gum or the use of straws to chew

was used in 5 (45%) of the classes. Only one class had difficulty with hygiene of the straw

disposal; they required frequent reminder not to leave them lying around nor throw them on

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the floor. Gum chewing was effective for certain students. One student in particular chewed

strong cinnamon gum in order to maintain her arousal level up and increase her participation.

In the MOVE category, all participants (100%) had some students who used therapy balls as

chairs, T-stools, Disc’O Sit cushions, rocking chair, bean bags and/or who were allowed to work

in a variety of positions. The use of an ironing board as a work surface was offered in two of the

classes so students could work in standing. Participants reported that, for certain students, the

use of a seating option allowing for some movement increased their ability to focus and attend

to their tasks. Structured movement breaks were done with 8 of the 11 (73%) classes; all these

movement routines incorporated heavy work such as chair push-ups, weight bearing walks,

pushing the wall or isometrics with their upper extremities. The change of seating option was

the most common strategy that participants used to help students with their self-regulation.

Some students required more individual movement breaks and 7 of the 11 (64%) participants

allowed their students the opportunity to leave the classroom to deliver a box of heavy books,

carry a weighted back pack or help the janitor with chores. The use of an old inner tube from a

bicycle, tied around the lower part of the two front legs of a chair, permitted students to rest

their feet and push against the resistive band. This strategy was used with certain students in 8

of the 11 (73%) classes. This worked for students who were unable to touch the floor with their

feet when seated at their desk; it also provided proprioceptive input and helped those students

who swung their legs and needed to move. Participants reported that the use of proprioceptive

input helped to calm students. Daily yoga postures and animal walks were used in one

kindergarten class; the participant reported that it made a difference in students’ behaviour if

these exercises were done.

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For LISTEN/auditory strategies, all (100%) of the participants used their voice to help self-

regulate their class. They altered the rhythm, volume and tone as needed. This strategy was

used the most often of all the auditory strategies. The second most common auditory strategy

used was noise reducing headphones or ear plugs. These were available in 7 of the 11 (64%)

classes and the participants reported that this helped several students focus better on their

tasks. Soft, calm music in the background was used by 4 of the 11 (36%) participants. In a grade

6 class, students were allowed to listen to music individually while working and this was

particularly successful. A student in a Grade 3 class worked longer and more focused when

allowed to listen to rhythmic music on an MP3. The use of sound to help transition from one

subject or task to another was used and reported to be successful in four (36%) classes. Two of

these participants beat a rhythm on a drum to get the attention of students and announce the

transition; the other used a soft bird call whistle and the forth participant used his hands to clap

out a rhythm.

For LOOK/visual strategies, 7 of the 11 (64%) participants used a Time Timer® or hour glass

and reported that this tool was helpful for time management and provided the students a

visual to help transitions. Another strategy that was used was the change of lighting; natural

light from outside was used instead of the fluorescents in the class. Of the 11 participants, 5

(45%) used alternate lighting regularly. The use of desk screens for individual students was used

in 3 (27%) of the classes. Visual cues such as gestures or pictograms were used by 5 of the 11

(45%) participants.

For TOUCH/tactile strategies, 9 of the 11 (82%) participants introduced fidgets for their

students to use while working or listening in class. They reported that initially, everyone wanted

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one but, as the novelty wore off, only those who benefit end up keeping it. The use of fidgets

was the most popular tactile strategy used by participants. One participant, a kindergarten

teacher, began using massage in class. Her students were taught a few simple massage

techniques and massaged each other’s back when they came in from recess. She reported that

this helped calm everyone down and made the transition back to class smoother.

Two participants installed a quiet space in the classroom. One used a small tent and the

other wrapped the legs of a table with fabric to create an enclosed space and placed cushions

inside. This quiet and low in visual stimulation retreat was helpful in preventing outbursts from

certain students; they could ask to sit in the quiet tent if they felt the need to calm down.

Discussion with teachers on sensorimotor strategies. Teachers used sensorimotor strategies

for both the whole class or with individual students only. As one student said to his teacher, “I

know that taking deep breaths when I’m upset helps me cool down.” Whole class strategies

included movement breaks with proprioception/heavy work, visual support such as the use of a

Time Timer®, respiration and massage. Fidgets were introduced to the whole group but not

everyone required their use. Initially, for most individual strategies, everyone wanted to use

them (e.g. T-stool, fidgets for the hands, chew sticks or gum) but as the novelty wore off, only

those who needed it continued to use it. A few teachers reported that they noted a large

benefit of using a sensorimotor strategy for certain students. “Students need to move, just as I

do all day,” stated one teacher. A few students, were able to put the strategy (e.g. T-stool)

aside and continued being self-regulated without it.

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It was to be noted that movement strategies such as getting up to move around and return

to their desks were reported to be less effective unless it was followed up by a proprioceptive

exercise such as chair push-ups or isometrics.

It was noted that the personality of teachers appeared to influence their first choice of

sensorimotor strategies introduced in their classroom. In OPC sessions, problem solving was

done together and they chose what was feasible and possible for them. However, when their

choice of action to attain their goal did not bring about the change they desired, they were

willing to step out of their comfort zone. In particular, two teachers with over ten years of

experience reported that this study had brought them out of their comfort zone and they were

happy to have done it. They said it made a big difference for their students and how they

perceive and manage classroom behaviour.

Overall, participants tried several sensorimotor strategies and reported that using them

made a difference in the behaviour of their students. They reported that now that they were

seeing the benefit, they would certainly continue using them as incorporate these new tools

into their future classrooms.

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Chapter 6. Discussion and Conclusion

Most school-based occupational therapy studies have focused on the students (Bayona,

McDougall, Tucker, Nichols, & Mandich, 2006; Dankert, Davies, & Gavin, 2003; Ohl et al., 2013;

Wehrmann et al., 2006). This pilot study focused on the occupational performance of the

teacher. The purpose of this study was to examine the extent to which a one day workshop

followed by a series of Occupational Performance Coaching (OPC) sessions can be used with

teachers to improve their perceived occupational role in addressing the demands of teaching

students with disruptive classroom behaviours. This study provided an innovative approach to

the provision of school based services. Another new program, Partnering for Change (Missiuna

et al., 2012), emphasized the partnership with the teachers and focused on collaboration and

coaching; this was similar to OPC. However, that study focused on services for children with

Developmental Coordination Disorder, while our study did not focus on a student group with a

particular diagnosis but, rather, on regular elementary school teachers meeting a variety of

student needs. This is similar to another pilot study where occupational therapy services

targeted the whole school rather than students with special needs; they aimed to increase the

knowledge and skill of teachers in order for them to meet the occupational needs of students

(Hutton, 2009).

Previous studies on OPC indicated that participants were satisfied with the process and felt

supported in achieving their goals (Graham, Rodger, & Ziviani, 2013; Kennedy-Behr, 2013).

Similarly, in the present study the results improved the satisfaction of 91% of the teachers.

Although measured by two different outcome measures, the sense of self-efficacy of 73% of

teachers improved as did the sense of self-efficacy in mothers during the OPC study (Graham et

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al., 2013). This pilot study joins the few other studies to support the use of OPC in helping

individuals attain their goals (Graham, 2010; Graham et al., 2013; Kennedy-Behr, 2013). In

addition to clinically significant change post-intervention, the majority of teachers maintained

their progress at follow-up several weeks later. Sustained improvements were also noted in the

use of OPC with mothers (Graham et al., 2013).

Following the recommendation of studies showing that teachers required additional

education to effectively address the issues of students with special needs (Kokkinos et al., 2004;

Reid et al., 1994), a one day workshop (Tools to Improve Attention and Self-Regulation for

Students in the Classroom) was provided in this study. However, knowing that this format of

instruction may not be optimal for knowledge uptake and, thus, change to occur, the workshop

was followed by a series of OPC sessions. This approach permitted the teachers to discuss and

problem solve with the knowledge they learned from the workshop and then apply it in their

classrooms. This was in line with recommendations for knowledge translation and practice for

change to occur (Carrier, Levasseur, Bédard, & Desrosiers, 2012; Dreeben, 2010; Thomas et al.,

2011). As well, it supported the Knowledge to Action Process by building on professional

development and tailoring it to the client (Graham et al., 2006).

Although not the main focus of the objectives of this study, the Alert Program® and

sensorimotor strategies were used by teachers during the study. Hence, this research also

provided some evidence on their use in classrooms. An overview of the Alert Program® was

taught during the one day workshop. However, in contrast to earlier studies (Barnes et al.,

2008; Cahill, 2006; Zeidler, 2012), teachers did not explicitly follow step by step procedures on

how to implement the Alert Program®. In this study, they used the vocabulary, explained the

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general concepts and provided the sensorimotor strategies to help students self-regulate in

their classroom. As indicated by Goal Attainment Scaling (GAS), clinically significant change

occurred for teachers’ goals pertaining to the overall classroom management and for specific

students; hence, this research joins other studies to support the use of the Alert Program® in

schools (Barnes et al., 2008; Buchanan, 2011; Chiodo, 2010; Spillane et al., 2011; Wells et al.,

2012; Zeidler, 2012). Unique to this study, a follow-up interview was done several weeks after

post-intervention measures were completed in order to explore whether change was

maintained. Results indicated that the improvements were maintained and teachers reported

that they could transfer their skills to other situations not targeted by their goals.

The tradition of students sitting up straight on chair appears to be fading. Teachers in this

study allowed their students to sit on therapy balls, T-stools, rocking chairs, and disc ‘o sits to

provide some movement while working. Teachers reported that students were more self-

regulated in this type of seating configuration. Similar studies have been reported in studies on

alternative classroom seating (Auld & Burgman, 2011; Fedewa & Erwin, 2011; Pfeiffer et al.,

2008; Schilling & Schwartz, 2004; Schilling, Washington, Billingsley, & Deitz, 2003). This is

different than what was reported in a study with students (n = 6) with Autism Spectrum

Disorder where results were mixed. They reported that students who seek vestibular-

proprioceptive input are more likely to benefit from a therapy ball chair than those with poor

postural stability (Bagatell et al., 2010). Hence, the importance of providing education to the

teacher in order to help her understand the patterns of sensory processing and its impact on

behaviour rather than simply using alternative seating because it is available.

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Minimal research exists on the use of proprioceptive/heavy work input to help organise and

calm students either in groups or individually. Participants in our study favoured the use of

proprioceptive input/heavy work with students. For example, they provided old bicycle inner

tubes from tires to tie on the two front legs of their chair; this allowed students to fidget their

feet against resistance. Another example was the use of chair push-ups following a movement

break. They used these strategies daily or as needed and reported these strategies most

effective in group situations or for individual students. What they report supports the research

that proprioception/heavy work can have a calming and organizing effect on students (Blanche

& Schaaf, 2001; Lopez & Swinth, 2008).

Teachers noted that, for certain students, allowing them to put something in their mouth

such as gum or a straw to chew on may have helped the student stay focused. While other

studies have specifically showed that chewing was positively associated attention to task

(Johnson et al., 2013; Tanzer et al., 2009; Tucha et al., 2004), this study provided some evidence

that chewing can help students self-regulate. Some teachers reported that they heard less

mouth noises when chewing on gum or a straw from those who exhibited these behaviours

otherwise. Another teacher reported that this was particularly beneficial for more quiet

students who tended be more on the “low engine” side. For students who had the tendency to

chew their pencil, shirt collar, or other non-food items, perhaps for self-regulation purposes,

the use of gum helped decrease the chewing of those items. In contrast to studies on the

benefit of chewing, one study (n=64) indicated that chewing gum showed no significant

difference for vigilance in both healthy children and those with ADHD. Interestingly, their

results indicate that the vigilance of both groups of children decreased when performing a task

87

while chewing gum (Tucha et al., 2010). However, these results were observed for the first 12

minutes of the 15 minute task studied; this may indicate that perhaps the benefit of chewing

occurs later. Another study confirms that the benefits of chewing gum on attention to task are

not immediate (Tucha & Simpson, 2011; Tucha et al., 2004).

The use of breath work (e.g. taking deep breaths, being aware of the breath, slowing down

its pace) to support self-regulation was also reported by teachers to be beneficial. Their daily

logs reflect that 82% used it almost on a daily basis. Studies on approaches incorporating the

breath reported its importance in self-regulation (Case Smith et al., 2010; Garg et al., 2013;

McGlauflin, 2010; Napoli et al., 2005). Knowing this, perhaps incorporating “breathing lessons”

or specific classes on self-regulation in the curriculum may be helpful to both teachers and

students. At present, there are evidence-based programs available to promote self-regulation:

Tools for the Mind (Barnett, 2008), Alert Program® (Williams & Shellenberger, 1996) and Zones

of Regulation® (Kuypers, 2011), the latter two incorporating breath work. As well, a Canadian

Self-Regulation Initiative has been established since 2012; their mission is to promote

education on self-regulation. They have supported eight school districts in British Columbia and

the Government of Yukon in the implementation of self-regulation instruction, based on the

Alert Program®, in their schools (Canadian Self-Regulation Initiative, 2013). Documentary

reports have been positive (Canadian Broadcasting Corporation News, 2013; Wells, 2013). Our

research study results add preliminary evidence that supporting self-regulation in schools

benefits teachers and students.

It is important to note that the usual research on sensorimotor strategies are specific to one

tool or strategy (e.g. Auld & Burgman, 2011; Case Smith et al., 2010; Fedewa & Erwin, 2011;

88

Garg et al., 2013; Johnson et al., 2013; Rowe et al., 2011; Schilling et al., 2003). In our pilot

study, since the focus was on the teachers and their occupational performance with self-

regulation, they had access to several strategies and tools. The focus was not to measure the

effect of particular strategies or tools. As well, the study design was such that teachers changed

the tools or strategies as needed to support for self-regulation in the classroom. Within the

length of the study and regular OPC sessions, they had the time to try and discuss a number of

strategies and find the ones that benefited the whole class or individual students the most.

The use of the Canadian Measure of Occupational Performance (COPM) and GAS

instruments in this study provided individualised outcomes measures relevant to each teacher.

As reported in other studies, using them together has been found beneficial (Cusick et al., 2006;

Doig et al., 2010; Ostensjo et al., 2008). It was useful in transforming the broader COPM issue

into a specific GAS goal. As well, the COPM captured the perception of the performance and

satisfaction of the attainment of the goal whereas GAS captured the functional level of the goal.

A disadvantage to GAS is the time consumption to scale each goal and its possibility for bias

when developing the scales (Kiresuk et al., 1994). By using the COPM and GAS in combination,

more comprehensive results were obtained regarding each of the teachers.

While teachers in regular classrooms face a multitude of student needs and disruptive

behaviours, school-based occupational therapists tend to focus directly on the students.

Perhaps we must consider a shift in service delivery. The traditional approach of consulting and

providing recommendations to teachers may not be effective (Lewis & Newcomer, 2002).

Results from this pilot study indicated that providing a traditional workshop which was followed

89

by a series of OPC sessions was a promising model that could be used by school-based

occupational therapists in order to support teachers and, indirectly, their students.

Limitations

Several limitations of this pilot study are noteworthy. In particular, the teachers volunteered

and invested their time in the intervention; this may have created a positive bias towards

change. The majority of participants considered their students to have moderate behaviour

issues in class. This may limit the generalizability of results to other teachers with varying

severity of classroom behaviour or it may have been an important factor in the positive findings

of this research. Another limitation was the absence of a control group; the use of an

experimental design with comparison groups would indicate whether improvements observed

were specifically attributed to the intervention.

Although measures were taken to ensure GAS goals and OPC were done adequately through

direct communication and consultation with experts in these techniques, the primary

researcher collected baseline measures, performed the intervention as well as collected post

and follow-up measures. When using GAS, bias is more likely to occur if goals are scaled by an

involved therapist; in this case, the primary researcher scaled the goals. In future studies, an

independent therapist would ideally scale the goals and carry out the post and follow up

measures.

Implications for Occupational Therapy Practice

One of the key practice implications from these findings is support for the use of OPC as a

promising approach for effective and efficient school-based occupational therapy service

90

delivery to improve self-efficacy and perceived occupational performance of teachers dealing

with complex behaviours in the classroom. OPC can be useful in improving their perceived

performance, satisfaction of their performance, and self-efficacy as well as attain specific goals.

In addition, the method of uptake of new knowledge, gained through a workshop and

regular support, must not be underestimated. When teachers gain a better understanding of

behaviours and self-regulation issues, they may be more likely to successfully support their

students. The role of the occupational therapist in effectively imparting knowledge and acting

as an agent of change is critical.

Directions for Further Research

Upon completion of this study, it is apparent that future research is needed in several areas.

An experimental design with comparison groups (e.g. randomized control trial) is needed to

further validate preliminary research on the use of OPC with teachers. The use of independent

pre, post and follow-up interviewers blind to the participant’s group would be critical as would

an independent observer to perform the classroom observations pre and post-intervention. In

this case, follow-up measures were taken 7.4 weeks post intervention data collection. Taking

follow-up measures at a later time point could provide more information on the sustainability

of the change over a longer period.

Research comparing OPC with traditional consultation used with teachers would be useful

given the latter is an approach widely used in the schools. As well, looking at the personalities

of the teachers for which OPC would be most useful would be an important area for future

research. In addition, knowing that occupational therapists frequently provide in-services and

91

teach workshops for teachers, studies on the effectiveness of these traditional methods to

impart knowledge on self-regulation without the follow up of OPC sessions are suggested.

Further studies are indicated to clarify if teacher-based OPC may lead to teacher mediated

school-based improvements. That is, to determine if expanding a teacher’s understanding of

the basis for challenging behaviours and their use of strategies to help students with self-

regulation, may lead to improvements in their students’ behaviours. When understood and

used appropriately by the teachers, the implementation of the Alert Program® and the use of

sensorimotor strategies may improve their students’ self-regulate and attention in the

classroom. This question is definitely one for future study.

As well, in the area of knowledge translation research, further studies on the use of follow-

up methods after continuing professional education may lead to improving the dissemination of

knowledge.

Conclusion

Research has provided us with evidence that elementary school teachers are stressed,

fatigued, and do not have adequate classroom support in working with students with special

needs. As occupational therapists, our enabling role in understanding occupational roles and

occupational performance issues can be utilized to support teachers in the classroom and may

have an indirect positive effect on their students.

This is the first study to explore the use of OPC with elementary school teachers; it is an

innovative approach to improving their occupational performance. In this pilot study, significant

results indicated that teachers improved on their specific goals after intervention of a one day

workshop and eight sessions of OPC; the teacher’s perception of performance improved as well

92

as their satisfaction of performance and self-efficacy. Teachers in our study reported that they

felt supported and were able to make improvements and maintain them. If we want our

students to succeed, we must enable the occupational performance of their teachers.

93

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i

Author/year Study objectives Design Sample size/participants

Intervention/Outcome measures

Summary of results Study Limitations

Barnes, Vogel, Beck, Schoenfeld, and Owen, 2008

To what extent does the use of the Alert Program® result in improvement in 1) sensory processing, 2) self-regulation, 3) behavioural adjustment skills of children with emotional disturbance as reported by children and teachers?

Quasi-experimental pretest/post-test design with a control group

n = 12 (n = 7 intervention group, n = 5 in control) ages 9 to 11 years old four classrooms for children with emotional disturbance

8 weeks of intervention using the Alert Program as described in the program manual. -Sensory Profile -Devereux Behaviour Rating Scale (DBRS)– school form -Measures of Self-Efficacy for Self-Regulation -Teacher’s Perception of Student’s Self-Efficacy in Self-Regulation

(p = .10) Not statistically significant pre and post-test for Sensory Profile. DBRS: three with significant changes in intervention group (interpersonal skills, appropriate behaviour and feelings, depression, and physical symptoms/fears) Measures of Self-Efficacy for Self-Regulation: group effect of 0.18. Teacher’s Perception of Student’s Self-Efficacy in Self-Regulation: intervention group improved over time with effect size 0.25.

Small sample size, study done in special needs classroom with much structure and few students thus limits generalization, participants had differing medication profiles

Buchanan, 2011

Can children’s sensory processing abilities be enhanced to better attend and thereby improve academic and social functioning in the kindergarten classroom?

Non-randomized controlled trial using a pre-test post-test design Unpublished thesis

Kindergarten students in two classes

6 months using weekly small group activities and daily center time activities based on Alert Program® -School Functional Assessment (SFA) -Sensory Profile (SP) - short form -Sensory Processing Measure- home and classroom (SPM)

Significant changes within the SFA-Part III Activity Performance/cognitive/behavioural tasks. SP: used only with intervention group and results indicated significant changes in two of eight areas. SPM Classroom form indicated significant improvements in over half of the eight areas assessed. SPM Home form indicated significant findings in three of eight areas.

At this time, complete thesis not available through Interlibrary loan (only in 2014) and no response from supervisor of Buchanan when contacted by email. No contact info on author

Appendix A- Appraisal of resources on Alert Program®

ii

Author/year Study objectives Design Sample size/participants

Intervention/Outcome measures

Summary of results Study Limitations

Cahill, 2006 Help a teacher manage difficult behaviours in the classroom using the Alert Program®.

Retrospective case study

Classroom of 31 first grade students with focus on one boy.

Over three weeks, three sessions with whole class and collaboration with teacher on ongoing basis. Teacher self-report to occupational therapist.

Teacher reports successful and continual use of Alert Program® in her classroom.

Single case study, no valid outcome measures.

Chiodo, 2010 In children between the ages of five and 11 with self-regulation needs, does The Alert Program® help develop increased attention during small group occupation-based activities?

Pre and post test experimental design Doctoral thesis

n = 8 students between 5- 11 years old.

Twelve group sessions over a six week period based on Alert Program® manual with some modifications. - Time Off Task/Average Time on Task - Time Off Task/Average Time on Task -Chiodo Teacher Sensory Survey - a record of each time a student required a redirection.

Six of the seven students showed an increase of time on task. All six of those students demonstrated a greater time on task by over 25 percent of their original baseline measurements. Teacher reported a greater understanding of recognizing sensory behaviors in the students in the classroom as well as the potential for sensory activities to help improve student’s classroom behaviours.

No valid outcome measures, small sample size, author reports 6 weeks too short time frame.

Salls and Bucey, 2003

To share their experience in developing occupational therapy services in the middle school environment through the Alert Program®.

A retrospective narrative

Middle school students involved in the Lifelong Communication Skills Laboratory in two middle schools.

Teaching self-regulation strategies in a classroom-based setting based on the Alert Program

Results based on personal experience of authors. Use of Alert Program® with middle school students is successful. Demonstrates adaptability of the program when needed.

No outcome measures done, informative article.

Schoonover, 2002 Social skills group created to meet the needs of students with significant

A retrospective narrative

11 kindergarten, first and second grade students.

Three special education teachers, a speech-language pathologist, and an occupational therapist

Evaluation at the end of the year and discussion with parents and teachers, indicated improvements

No specific outcome measures discussed or

iii

Author/year Study objectives Design Sample size/participants

Intervention/Outcome measures

Summary of results Study Limitations

problems with social awareness, peer relationships, self- regulatory behaviors, and language expression

run the social group over the length of a school year.

All participants displayed documented improvements.

statistical analysis, informative article.

Wells, Chasnoff, Schmidt, Telford, and Schwartz, 2012

Will neurocognitive habilitation group therapy services improve executive functioning and emotional and social problem-solving skills in children with Fetal Alcohol Syndrome and Alcohol Related Neurodevelopmental Disorder?

Randomized controlled study- randomly assigned and evaluated by blind evaluators.

n = 78 (n = 40 [27 boys, 13 girls] in treatment group, n = 38 [26 boys, 12 girls] in control group) Aged 6 -11.11 years old Participants living in foster homes.

Twelve weeks of intervention with child group and separate caregiver group sessions using components of the Alert Program®. -Behaviour Rating Inventory Function (BRIEF) - Roberts Apperception Test for Children (RATC) -Wechsler Intelligence Scale for Children-Third Ed. (WISC-III)

BRIEF: treatment group showed significant improvement attributable to the intervention. Effect of 0.30. RATC: significant change noted in emotional problem solving. Effect of 0.28. PEDro Scale = 7/10

Participants lived in foster homes so less likely to generalize results. Initial assessment provided feedback to caregivers of both groups. This may have muted the changes between both groups if caregivers of control applied feedback given at baseline measure.

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Zeidler, 2012 Explored whether the Alert Program®, a comprehensive self-regulation program based on sensory integration theory, was an effective school-based intervention to improve attention to task in7-to 10- year-old students with sensory processing difficulties.

Exploratory study

n = 7 (6 with ASD and 1 with ADHD)

Six weeks of intervention with Alert Program® -Teacher Observation Scale -Students Self-Regulation Report Scale (both developed for study)

Teacher Observation Scale indicated increased student ability to stay focused: doubled the amount of ‘very’ and ‘somewhat’ responses responses Students Self-Regulation Report Scale: positive reports from students

Short duration of study, small sample.

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Auld and Burgman, 2011

To determine the impact of using stability balls and disc’o sit cushions on mainstream primary students’ sensory responses and handwriting outcomes.

Pre-and post-test experimental design

n = 18 7 -9 years old students in a regular grade 2/3 class

Students spent part of the day sitting on a stability ball or a disc’o sit cushion -Handwriting Speed Test -Short Sensory Profile -Sensory Profile School Companion

Handwriting Speed Test: (p ≤ 0.0001); word spacing (p = 0.0006); letter formation (p = 0.04); overall writing eligibility (p = 0.005) Short Sensory Profile: no significant difference Sensory Profile School Companion: Factors 1 (p = 0.004), 2 (p = 0.004), 3 (p = 0.004), 4 (p = 0.008)

No mention of differences for results between girls and boys. Small sample

Bagatell, Mirigliani, Patterson, Reyes, and Test, 2010

What effect do therapy ball chairs have on in-seat behavior? What effect do therapy ball chairs have on engagement? What are teachers’ perceptions on the use of the ball chair? What do children with ASD prefer to use as a seating device? Which children respond best to the use of the therapy ball chair?

Single-subject design- ABC design

n = 6 boys with ASD from K and grade 1

Baseline- phase A Each participant was fitted for a therapy ball and spent the duration of Circle Time sitting on it- intervention phase (B) occurred over 9 school days (over 2 weeks) Choice phase (C)- students had choice of regular chair or therapy ball. -digital video recordings were done for entire 16 minutes of Circle Time. In-seat behaviour and engagement were observed variables

Each child had unique response to use of therapy ball. Alex: Phase A average of M = 88.2 s out of seat, Phase B M = 22.8 s out of seat, Phase C (ball) M = 25.5 s out of seat. Engagement no change with or without therapy ball chair Jack: Phase A average of M = 26.8 s out of seat, Phase B M = 5.3 s out of seat, Phase C (ball and chair) M = 7 s and 11.7 s out of seat. Engagement inconsistent with or without therapy ball chair Roland: Phase A average of M = 29.4 s out of seat, Phase B M = 21.3 s out of seat, Phase C (ball) M = 49.6 s out of seat. Engagement no change with or without therapy ball chair

Engagement is a difficult construct to measure. Small n, measured at one specific activity (circle time), short duration of study, classroom distractors may have influenced behaviours.

Appendix B- Appraisal of Resources on Sensorimotor Strategies

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Samual: Phase A average of M = 105.8 s out of seat, Phase B M = 77.6 s out of seat, Phase C (chair) M = 64 s out of seat. Engagement more stable with therapy ball chair Omar: Phase A average of M = 7.6 s out of seat, Phase B M = 37.1 s out of seat, Phase C (chair) M = 36.2 s out of seat. Engagement changed minimally with therapy ball chair or chair At 1 year follow-up, teacher was no longer using therapy ball chairs during Circle Time or academics, only during sensorimotor time.

Case-Smith, Shupe Sines and Klatt, 2010

To understand the perceptions of 3rd grade students from a low SES neighborhood their experience with an 8 week yoga program.

Qualitative pre-post design

n = 21 all 3rd graders 9 boys, 12 girls in regular education

8 weekly 45 minute sessions during the school day of yoga (movement, relaxation, and breath work) -focus groups -drawing

Three themes emerged from focus groups: (1) feeling calm and focused “get all the hyperness out of me” (2) controlling their own behaviour “take a breath”, (3) supporting a positive self-concept “I feel like I’m in a good place”

Focus groups may have influenced the children’s responses; qualitative study cannot generalize results beyond group of students who participated in study.

Collins and Dworkin, 2011

To provide additional research on the effectiveness of weighted vests.

ABA design with random assignment to 2 groups: intervention and control

n = 13, 7 in intervention and 4 in control group students aged 7.5 yrs to 10.3 yrs

Participants wore the OT Vest (one was weighted, the other was not) Video recording of participants took place over

No significant difference between groups (p = 0.971) Within group effects non significant (p = 0.753), non significant interaction effect (p = 0.939)

Recording of movement may have been self-regulation rather than off task behaviour

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with difficulties staying on task (one had ADHD dx)

9 sessions, total recording of 90 min.

but was coded as such Wide inclusion criteria makes for variable sample Low power due to small sample

Edelson, Goldberg Edelson, Kerr, and Grandin, 1999

To determine whether 1. deep pressure affected behavioural indexes of anxiety 2. deep pressure affected physiological indexes of anxiety

Experimental pre-post design

n = 12 4-13 years old (9 boys, 3 girls) diagnosed with ASD Formed two groups: experimental and placebo

Two sessions of 20 minutes in the Hug Machine per week for 6 weeks. -Galvanic Skin Response (GSR) -Conners Parents Rating Scale (CPRS)

Correlation between the 3 CPRS scales the Anxiety and Tension Scale, Anxiety and Restlessness/Hyperactivity and the Tension and Restlessness/Hyperactivity with the GRS were significant. CPRS- Analysis of Tension Scale: significant decrease (p < 0.01), Analysis of Anxiety: significant decrease (p < 0.01)

Participant’s level of anxiety was moderate rather than high at baseline; use of Hug Machine was done with a schedule rather than times when participants felt most anxious; small sample; no self-report by participants since half sample was non-verbal.

Fedewa and Erwin, 2011

Does the use of stability balls increase the frequency of on- task and in-seat behaviour for

Single subject A-B continuous time series design using momentary time sampling

n = 8 from grades 4-5, 6 boys and 2 girls, 5 with diagnosis of ADHD others

Baseline data collection lasted two weeks (same 3 days per week for 30 min each participant). Participants observed 3

All students who participated had increased attention and decreased hyperactivity behaviours using the stability balls. The 8 participants changed the most.

Small sample size, 12 weeks may not have been long enough so that novelty effect

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students identified with attention and hyperactivity concerns? What are students’ and teachers’ perceptions of stability balls as chairs?

had behaviour concerns symptomatic of ADHD but no diagnosis 76 (including the 8) students from 4 classes were included in analyses on the effects of the stability ball intervention

times a week for 12 weeks during intervention period. -Attention Deficit/Hyperactivity Test - (ADHDT) -Teacher Social Validity Scale -in seat and on task behaviour using momentary time sampling

ADHDT scores decreased significantly for the 8 participants (p<.001). In-seat and on-task behaviour improved markedly from 45% to 94% for time in seat and 10% to 80% for time on task. Teacher Social Validity Scale indicated that teachers believe the stability balls to increase student attention, in seat behaviour and work completion.

wears off, may not be realistic to think that all students would get a stability ball due to lack of funds

Field et al., 1997 Investigated the effects of touch therapy on inattentiveness (off task behaviour), touch aversion and withdrawal on children with ASD.

Randomized control trial

n = 22 average age of 4.5 years old 12 boys, 10 girls with ASD

Experimental group received touch therapy for 15 minutes/day for 2 day/week for 4 weeks (8 sessions). Control group received same amount of time sitting on the lap of volunteer and playing games. - Early Social Communication Scales (ESCS) -Autism Behaviour Checklist (ABC) -observations

Touch aversion and off task behaviour decreased in both groups. Orienting to irrelevant sounds decreased significantly more in the experimental group (p < 0.05). Stereotypical behaviours significant decrease in experimental group (p < 0.01) ESCS: significant progress in joint attention (p < 0.05), behaviour regulation (p < 0.01), social behaviour (p < 0.05), and initiating behaviour (p < 0.01). ABC: decrease in sensory scale (p < 0.05), relating scale (p < 0.05), total scale score (p < 0.05) PEDro Scale 6/10

Small sample size, volunteers students administered the touch therapy

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Garg et al., 2003 To examine the Get Ready to Learn (GRTL) program’s effectiveness in improving the level of independence, attention, transition from one activity to another, and self-regulation of elementary students with disabilities when incorporated into the daily classroom curriculum.

Cohort study with pretest-post-test design

n = 51 elementary school students 5 to 9 years old receiving special education services in self-contained classrooms 43% multiply handicapped, 22% developmentally delayed, 35% with ASD

Implementation of the GRTL program for 12 to 26 weeks. -Get Ready to Learn Supplemental Data Sheet measuring four items: Independence, Attention, Transition, and Self-Regulation

Paired t-test showed statistically significant results on all four variables ( p = 0.000 for all four)

Small sample size, absence of a control group, non-validated measurement tool, lack of blinding because the teacher served as both the implementer and the observer of participants.

Hallam, Price and Katsarou, 2002

Study 1. Establish the effects of music on task performance. Study 2. Can you disrupt learning by playing music that was perceived as arousing, aggressive, and unpleasant?

Randomized control trial

Study 1: n = 31 from regular grade 6 classes, ages 10-11 years old music group and non-music (control) group Study 2: n = 30 (15 girls and 15 boys) 11-12 years old Non-music (control) group, unpleasant music,

Study 1: Arithmetic problems with fractures. Study 2: memory tasks

Students listening to background music (calm music) had better results on the math problems than the control (p = 0.02). Speed was enhanced and statistically significant, not accuracy (p = 0.12). Analysis of variance indicated significant difference between the 3 groups (p = 0.0002) Calming music had a positive effect of music on task performance and remembering words from sentences and pro-social behaviour. Arousing, unpleasant, and aggressive music had a negative effect on

Not clear if groups were similar. No eligibility criteria stated.

aggressive music group, and pleasant, calming music group.

performance on memory task and lower level of reported prosocial behaviour. PEDro Scale = 5/10

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Jensen, 2012 To investigate breathing patterns in young people with disruptive behaviour and the effect of Yoga Nidra technique on breathing.

Comparision between intervention and control group

n = 7 (Disruptive Behaviour (DB) group), boys aged 10-15 years old, mean age = 12.6 years, SD = 2 years. Six of the boys had a diagnosed mental health disorder, other had no diagnosis but exhibited externalizing and internalizing behaviours. n = 3 (comparison group), adolescents with mean age of 15.2, SD = 0.05 years

13 weeks yoga training program which included breathing exercises, postures, and Yoga Nidra. -Compumedic’s thoracic and abdominal Respiratory Inductive Plethysmography (RIP) and Summit IP with Profusion PSG. -Conners Teacher Revised: Long Version (CTRS-R:L) -State Trait Anxiety Inventory (STAI) -State Trait Anxiety Inventory for Children (STAIC) -Self-Description Questionnaire 1 and 2 (SDQ I and II)

Most students in the DB group displayed continuous fast, irregular and sometimes chaotic breathing in pre-intervention phase. 5/7 DB boys has more regular breathing despite being shallow following intervention. 7/7 displayed more normal patterns of amplitude or slower breathing rates. This study was part of a larger (n= 76) study where oppositional behaviour as noted on the CTRS-R:L was significantly reduced.

Small number of participants. Control group was older and had mixed gender. Analysis of breath patterns was limited to visual analysis of graphs.

Johnson, Muneem and Miles, 2013

1. On a sustained attention response task, are time on tasks effects observed? 2. Does chewing gum initially impair attention due to the division of resources?

For the behaviour data, a 2-factor (2 X 3) within participants design was used. For self-rated mood data, a 2-factor (2 X 2) within

n = 20 (10 female, 10 male with average age of 21 years old)

Tasks were done while chewing gum (Wrigley’s Cool Breeze) on one day and without chewing gum on the Day 2. -Sustained Attention Response Task (SART) -Bond-Lader Visual Analogue Mood Scales (VAMS)

Attentional task performance: the ANOVA revealed significantly shorter response times for the gum condition (p <0.001, effect = 0.52). No main effect of order of gum presentation, nor did this interact with other variables. Alertness on the SART indicated

Flavour was not taken into account. Mint may contribute to the changes. Results were immediate and not measured over prolonged

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3. What is the extent to which gum induced changes to task performance are independent of gum-induced changes in perceived alertness?

participants design was used.

that participants did better with gum (p < 0.001). Calmness post-SART was higher than pre-SART (p < 0.003). VAMS: perceived alertness and calmness were increased in the gum condition

period.

Kercood, Grskovic, Lee, and Emmert, 2007

To evaluate the effects of a small motor physical activity during an academic task on task performance.

Single-subject alternating treatments design

n = 4, 9 year olds, 3 boys, 1 girl with attention issues (no ADHD diagnosis)

Students able to use fidget tool (Tangle, Jr) during work task. Number of correct math problems, number of math problems completed, percent of off task behaviours for each 20 minute sessions.

2 of the 4 students had more correct math problems with intervention than without. All 4 students completed more math problems with intervention. More off task behaviour at baseline than with intervention (38% vs 21%, 35% vs 14%, 39% vs 21% and 28% vs 21%).

Small sample size. No students had ADHD diagnosis; results may have been different with more severe attention issues. Object to fidget with was selected for the students (may not have been their tactile preference). Setting was not in their typical classroom.

Kinnealey et al., 2012

Will students diagnosed with autism or dyspraxia exhibit increased attention for learning after

Mixed-method, multiple single subject AB (B + C) design

n = 4 male students aged 13-20 years old with language impairment, 3 with ASD and 1

Study took place over 6 weeks and included 3 phases: 2 weeks baseline before modifications, 2 weeks after installation of sound absorbing walls, and

Classroom sound: decibel readings were lower for sound averages and range as well as increased percentage of low readings.

Sample size, single location, design (doesn’t allow to return to baseline conditions)

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installation of sound absorbing wall material? After the installation of halogen lighting? From students’ perspective, do these modifications affect their ability to attend?

with dyspraxia 2 weeks after installation of halogen lights. -decibel meter to measure ambient classroom sound -journaling to record the subjective experience and objective of participants (feedback was given verbally by three and one typed responses) -Sensory Profile -videotaping to observe attending behaviours (blind evaluators)

Attending and non-attending behaviours: increased attention and decreased non-attending behaviours as recorded by percentages. Results with both modifications made indicated further decrease in non-attending behaviours. Journaling: all positive feedback to environmental modifications.

Lopez and Swinth, 2008

To determine the effect of a proprioception-based group exercise program on the physically aggressive behaviours of students with SPD in an elementary school classroom for students with behavioural disabilities.

Single subject A-B design

n = 3, 9 year old boys with ASD

A 5-minute proprioceptive program of five exercises done twice daily. -Sensory Profile (SP) -Short Sensory Profile (SSP) -Medical and Behavioural History Parent Questionnaire (developed for this study) -Behaviour Checklist Teacher Questionnaire (developed for this study) -observation of behaviour: collected data on incidents of physical aggression

SP and SSP: gave information on the sensory processing abilities of the students. Medical and Behavioural History Parent Questionnaire and Behaviour Checklist Teacher Questionnaire also gave information on confounding variables. Observation of behaviour: decreased duration of aggression for two of the three boys (p = 0.02, p = 0.002) and decreased number of aggressive acts for one (p = 0.035) Qualitative data was gathered from the teacher; she reported that the use of proprioceptive exercises had a profound effect

Small sample size, unable to watch the students an equal number of hours per day, not all three SP’s were returned.

on her whole class, including less arguing amongst students.

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McGlauflin, 2010 When teach self-regulation of learning related social skills using the mind, the body, and the breath, how can it help students?

Pilot – use of surveys pre intervention, midyear, end of year

n = 60, first graders from 4 classes

Intervention of body exercises, breath work, mind work for 30 minutes weekly for 38 weeks -Beginning and midyear survey with teachers -midyear survey of parents -assessment of concept mastery pre and post -anecdotal evidence through observation by staff

Results were so positive that this project was implemented in the following years. Both parents and teachers reported a marked difference in children. Students learnt the benefits of deep breathing as a way to self-regulate and they were able to use it spontaneously when needed.

Limited site-specific action research project. No formal data was reported.

Mulligan, 2001 What are general education teachers in northern New England commonly using as strategies in their classroom to effectively improve the performance of children with ADHD?

Survey of general education teachers from K through high school. Random sampling procedure chose 11 school districts and 2 were deliberately chosen with the intent to gather information for further research studies.

n = 151 demographic data indicated that all grade levels were represented and teachers with a wide range of experience participated

Survey instrument specifically designed for this study inquiring about the frequency of the use and perceived effectiveness of the following strategies: individual behaviour program, time-out, teach self-monitoring behaviour, environmental modifications, use quiet work areas, curriculum modifications, alternative evaluations, peer tutoring, assignment modifications, routine and structure, use of motor breaks, frequent contact, assistance during transitions, sensory modulation techniques

Strategies most frequently used: preferential seating, frequent contact, enforcing routine and structure. These were also perceived as more effective. Motor breaks were used 61%, environmental modifications 59% and sensory modulation techniques 26 %. Teachers reported the need for: Increased support personnel in class, specific teaching strategies, smaller class sizes, more education and training, parent support and involvement, change of teacher attitudes towards students with ADHD.

Low response rate, interpretation of some of the survey questions must be considered, generalizable to teachers in small, rural school districts and to those interested in teaching students with ADHD.

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Naploi, Rock Krech and Holley, 2005

Examines whether students’ participation in a mindfulness training program increased their ability to maintain their attention.

Randomized control trial

n = 228, 34 were excluded since they did not complete the full 12 trainings, therefore n = 194 students from 9 classrooms from 2 elementary schools

12 Attention Academy Program sessions held biweekly.For the intervention group, sessions included breathing exercises, body-scan visualization, movement activities and sensory stimulating activities. For the control group, sessions were conducted in a separate room where they could read or participate in other quiet activities. -ADD-H Comprehensive Teacher Rating Scale (ACTeRS) - Test Anxiety Scale (TAS) Test of Everyday Attentions for Children (TEA-Ch) -Selective visual attention meausres: Sky Search, Map Missions --Selective visual attention meausres: Sky Search, Map Missions

Paired t-test showed statistically significant results on TEA-Ch (p <0.001), ACTeRS social skills subtest (p<0.001), ACTeRS Attention subscale (p<0.001), and TAS (p<0.007). Effect sizes: ACTeRS Attention = 0.49 ACTeRS Social Skills = 0.47 TAS = 0.39 TEA-Ch selective = 0.60 PEDro Scale = 5/10

Did not use a priori pre-test covariance to control for naturally occurring differences between groups. No discussion on gender or ethnic differences.

Pfeiffer, Henry, Miller, and Witherell, 2008

Are Disc’O Sit cushions effective for improving the attention of second grade students with attention difficulties within the classroom?

Randomized control trial

n = 61 second grade students from six elementary schools

Treatment group used Disc’O Sit cushion to sit for 2 hours a day for a 2 week period. Control group sat in regular classroom chairs for same amount of time. Behavior Rating Inventory of Executive Functioning

GEC of the BRIEF indicated significant difference between treatment and control group (p < 0.05) Medium effect of 0.324. On the BRI, small to medium effect of 0.229, p < 0.05 between the groups.

Observational form as a method to determine inclusion in the study, teachers with higher incidence of students

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(BRIEF)- use of the Behavioral regulation index (BRI), Metacognition Index (MI) and the global executive composite (GEC)

On the MI, significant difference found between treatment and control groups (p < 0.05) with effect size of 0.145. PEDro Scale = 6/10

meeting inclusion criteria seemed to be more in favor of the study, teaching style of teachers, lack of blinding teachers to group assignment

Rowe, Candler and Neville, 2011

The purpose of this study was to investigate whether decreasing auditory sensation with the use of noise reducing headphones would impact attention to task in a child with auditory defensiveness.

A-B-B-A single subject experimental design

n = 1, 11 year old boy with ASD

Intervention: use of a Peltor brand headphone with a noise reduction rating to 22 dB -American Recorder sound level meter -data recording form to record amount of time attending to task

Visual analysis shows increased levels of task attention when using headphones in all intervention phases of the study. Average time difference between baseline and intervention sessions for attending to the task = 158 s

Single subject, lack of validated measures to measure outcome

Schilling and Schwartz, 2004

What effect does using therapy balls as chairs have on in-seat behaviour? What are effects of sitting on therapy balls on engagement? What ere teachers’ perception on th e use of therapy balls for seating?

Single subject withdrawal design

n = 4 boys aged from 3 years 11 months to 4 years 2 months ASD diagnosis

Intervention (sitting on ball for maximum of 10 minutes a day for a period of 3 weeks) of using the therapy ball as seat was delivered in an A-B-A-B design for 3 participants and B-A-B for 1. Sitting and engagement outcomes were measured using momentary real-time sampling Social validity measured through staff questionnaire.

Percent of intervals for in-seat behaviour and engagement improved substantially for all 4 participants. All staff supported the use of therapy balls as indicated by the questionnaires.

Sample size, short time on the ball during the day, short intervention phase

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Sessa, 2007 To describe the effects on stress, mood, and behaviour of students and teachers following teacher in-service workshop centred around breath and meditation.

Qualitative data gathered post workshop

Elementary school teachers of grade 3,4,5

One-hour teacher in-service on breath, meditation and focus training. Teachers share knowledge with students and practice with them 5 minutes a day.

Positive comments from teachers following workshop. 100% reported that they now understand the importance that breath has on stress. 92% reported that they felt it would be useful with their students. 85% reported that they have an understanding of how to practice meditation. Follow-up from principal reported that workshop had impact on staff and on students. During the grade 3 & 4 state testing the school environment was calmer and more relaxed.

Number of participants not reported. Follow-up was informal. No information from students perspective.

Silva, Schalock and Gabrielsen, 2011

1. Do children who receive the Qigong Sensory Training (QST) Home Program improve in the classroom setting on measures of autistic behaviour as evaluated by preschool teachers blind to the group? Do they improve in the home setting on measures of autism and sensory and self-regulation as reported by parents?

Randomized control trial

n = 47 children aged 3 to 6 years old (33 boys and 14 girls) with ASD

Intervention of 15 minutes of QST protocol (patting, shaking or pressing movements on the child’s body done by the parents) Autism Behaviour Checklist (ABC) - parent version of Pervasive Developmental Disorders Behaviour Inventory (PDDBI) -Sense and Self-Regulation Checklist (SSC) -Autism Parenting Stress Index (APSI)

Significant improvement for treatment group participants: Effect size ≥ 0.60. Teacher measure on ABC: improvement (p = 0.00045) Parent measure on PDDBI: sensory score (p = 0.0003); Maladaptive Behaviour (p = 0.00001); Social/Language/Communication Abilities (p = 0.001) SSC: Sense Checklist (p = 0.0001), Self-Regulation Checklist (p = 0.00003) PSI: (p = 0.00001) PEDro Scale: 7/10

Baseline level of skills taught to parents were not enough for children with more severe autism

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2. Do children in the Home Program and the Dual Program experience equivalent outcomes on the measures of autism and sensory and self-regulation? 3. Are there differences in outcomes between the Dual and the Home Program interventions relative to the severity of autism and the severity of parent stress?

Schilling, Washington, Billingslley, and Deitz, 2003 (included in Worthen’s 2010 Critical Appraisal)

To investigate the effects of therapy balls as seating on in-seat behaviour and legible word productivity with students with ADHD and to assess social validity of teachers and students regarding the intervention.

Single subject A-B-A-B interrupted time series

n = 3 2 boys and 1 girl with ADHD diagnosis from 4th grade class all 24 students in the class used the balls

Therapy ball provided for all students of the 4th grade class In-seat behaviour measured using momentary real-time sampling Word legibility was measured using Hasbrouck, Tindal, and Parker method (blind evaluation of the samples)

All participants increased in-seat behaviour. Word legibility was higher when seated on therapy balls. Social validity: the 3 participants preferred therapy balls as chaired as did the majority of the class. Teacher also preferred the therapy balls. After the study, she purchased therapy balls for the class.

Short duration of study, sample size, use of single classroom, the word legibility did not include looking at spelling, sentence structure or content

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Tucha, Mecklinger, Maier, Hammerl, and Lange, 2004

Are memory and a variety of attentional functions affected by gum chewing?

2 groups- both tested under 4 conditions

Group 1 n = 58 (29 male, 29 female with mean age of 22.9 years) Group 2 n = 58 (29 male, 29 female with mean age of 22.2 years)

Tested under four conditions: no chewing, mimicking chewing, chewing piece of sugarless, tasteless gum and chewing a piece of spearmint gum. Memory was measured with 15 noun recall. Computerized neuropsychological assessment of attention deficits. Visual vigilance task.

No significant differences found in measures of divided attention, selective attention, visual scanning or vigilance. Increased sustained attention was significant with chewing of spearmint gum. Memory functions were not improved. Alertness and flexibility were adversely affected by chewing.

Testing measures had little ecological validity; the testing should have taken place in a classroom or workplace.

Tucha, Simpson, Evans, Birrel, Sontag, Lange, Tucha, 2010

To test whether chewing gum improves vigilance and sustained attention in children with ADHD as compared to a group of healthy children

Crossover design

n = 64 ADHD group (n = 32) 8 girls, 24 boys mean age = 10.8 years Healthy group (n = 32) 8 girls, 24 boys mean age = 10.6 years

Chewing gum while performing computerized tests for 15 min. Computerized attention test measuring vigilance and sustained attention. Reaction time for correct responses, number of omission errors (lack of response to target stimuli) and number of commission errors (responses to non-target stimuli) were calculated

Children with ADHD made more omission errors when chewing gum (p =0.47). No significant difference was found between chewing gum and not chewing gum for healthy children (p = 0.576 for reaction time; p = 0.413 for commission errors; p = 0.116 for omission errors). No significant difference was found between chewing gum and not chewing gum for children with ADHD (p = 0.737 for reaction time; p = 0.793 for commission errors; p = 0.862 for omission errors).

15 minutes may be short time to use; may need novelty to wear off. ADHD children were medicated - may have been different without medication.

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Verret, 2012 To assess the effects of a moderate to high intensity physical activity program lasting 10 weeks on fitness, cognitive functions and behaviour in children aged 7 to 12 with ADHD.

quasi-experimental design with a non-equivalent control group as a control on the physical activity program Doctoral thesis

n = 21 10 (9 boys and 1 girl) in intervention group and 11 )10 boys and 1 girl) in control group aged 7 to 12 years old with ADHD with or without medication and children without ADHD

Intervention: 45 minutes of moderate to high intensity physical activity three time a week during lunch hour. -anthropometric measures -musculoskeletal aptitudes -Test of Gross Motor Development-2 (TGMD-2) -Bruce treadmill protocol -height, weight, body mass index (BMI), flexibility, muscular endurance, resting and maximal heart rate -behaviour was measured with Child Behavior Checklist (CBCL)- parent and teacher forms - Attention functions and response inhibition: measured by the Test of Everyday Attention for Children (TEA-Ch)

Motor skills showed significant (p < 0.05 ) improved in treatment group (p = 0.006). CBCL- impulsivity decreased significantly, p = 0.035. Attention improved on CBCL and TEA-Ch. Program did not affect all the ADHD core symptoms but had significant impact on information processing and on other important functional domains such as social skills and behaviour in ADHD group (p < 0.03)

Sample size, no information on the dosage of medication, parents and teachers not blinded to which group participant was in

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Worthen, 2010 For pre-school through elementary school aged children with and without developmental diagnoses, do sensory-based intervention strategies used in the general classroom result in improved attention and/or acad. perf.

Critical appraisal of 13 articles (12 level I, II, IV, and V quantitative and 1 qualitative)

13 articles: 2 level I 2 level II 6 level IV 2 level V quantitative and 1 qualitative published prior to 1990

Implementations of the use of auditory, tactile, visual, olfactory, gustatory, vestibular and proprioceptive strategies may be used and encouraged by OT’s

Few level I

Appendix C

Teachers’ Sense of Efficacy Scale: Classroom Management subscale

Teachers’ Sense of Efficacy Scale: Classroom Management subscale

By: Tschannen-Moran & Woolfolk-Hoy (2001)

Name :_______________________________________________ date: __________________

Directions: This questionnaire is designed to help us gain a better understanding of classroom management for teachers. Please indicate your opinion about each of the statements below. Your answers are confidential.

1.How much can you to control disruptive behaviour in the classroom?

(1 (2) (3) (4) (5) (6) (7) (8) (9)

2. How well can you establish routines to keep activities running smoothly?

(1 (2) (3) (4) (5) (6) (7) (8) (9)

3. To what extent can you make your expectations clear about student behaviour?

(1 (2) (3) (4) (5) (6) (7) (8) (9)

4. How much can you get children to follow classroom rules?

(1 (2) (3) (4) (5) (6) (7) (8) (9)

5. How much can you do to calm a student who is disruptive or noisy?

(1 (2) (3) (4) (5) (6) (7) (8) (9)

6. How well can you establish a classroom management system with each group of students?

(1 (2) (3) (4) (5) (6) (7) (8) (9)

7. How well can you keep a few problem students from ruining an entire lesson?

(1 (2) (3) (4) (5) (6) (7) (8) (9)

8. How well can you respond to defiant students?

(1 (2) (3) (4) (5) (6) (7) (8) (9)

Not

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Appendix D Sample calculation of Reliable Change (RC) Index

Sample calculation of Reliable Change (RC) Index:

RC= x2 – x1

Sdiff

where x1 is the participant’s pretest score, x2 is the same participant’s post test score, and Sdiff is

the standard error of difference between the two test scores. Sdiff can be calculated directly

from the standard error of measurement SE according to this:

Sdiff =�2(SE)2

Sdiff refers to the spread of the distribution of changes scores that would be expected if change

occurs. s1 is the standard deviation of the measure.

SE = s1�1 − 𝑟𝑒𝑙𝑖𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑚𝑒𝑎𝑠𝑢𝑟𝑒

In the Classroom Management subscale, the reliability of measure is 0.90, the mean is 6.7

and standard deviation is 1.1.

Participant 11 : TSES-CM pre = 5.9; post = 5.0

SE = s1�1 − 𝑟𝑒𝑙𝑖𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑚𝑒𝑎𝑠𝑢𝑟𝑒 = 1.1 (( √1 − 0.90)) = 0.35

Sdiff =�2(SE)2 = �2(0.35)2 = 0.49

RC= x2 – x1 = 5.9 – 3.9 = 4.08

Sdiff 0.49

RCI is clinically significant when ≥1.96

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Appendix E Questions for post1 and follow-up debriefing

Questions for post1 and follow-up debriefing:

• What do you feel you learnt from participating in this research study? • In a few words, can you describe what you feel has changed in how you view a students’

behaviour? • In the past few weeks, what do you feel has changed about your ability to manage

challenging behaviours. • Please describe what you understand about self-regulation. • Please describe what you are presently doing to address challenging behaviours in the

classroom:

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Participant #________ Session #_______ Date______________

Appendix F OPC-Stroke Fidelity Checklist Tick the items that occurred during the session and rate the related times that follow ___ Facilitated Goal Setting

a) PPA was used to set goals

YES NO

b) Participant was provided with a written copy of his/her goals

YES NO c) Collaboration during Goal Setting1

1 2 3 4

The Coach actively assumes the expert role for the majority of the interaction with the participant. The Coach minimizes participant ideas for goals

The Coach favors supplying knowledge or expertise. The coach seeks participant input into goals but directs the selection and definition of the goals

The Coach promotes the participant’s goals, ideas and values but does not do so consistently. The Coach may implicitly influence participant’s selection of goals.

The Coach fosters collaboration and power sharing so that goals are selected, and defined by the participant. The Coach explicitly identifies the participant as the expert

___ Problem Solving Process (Tick steps and compete a) below) ___ Explore options (Complete b), c), d), e) below)

Goal #1 Goal#2 Goal #3 ___ Plan action steps (Complete f) below) Goal #1 Goal#2 Goal #3 ___ Carry out plan (review of what was done) Goal #1 Goal#2 Goal #3 ___ Check performance Goal #1 Goal#2 Goal #3

xxiv © Dorothy Kessler Jan 31, 2013

Participant #________ Session #_______ Date______________

___ Generalize (Review of strategies, tools and resources used to achieve goals Encouragement provided to continue to use goal-focussed problem solving process)

a) Participant received a handout illustrating the problem solving process

YES NO

b) The coach presented and explained the PEO model

YES NO c) Participant received a handout illustrating the PEO model

YES NO d) Collaborative performance analysis process was used

For: Goal #1 Goal#2 Goal #3 None

Tick the aspects of collaborative performance analysis used

___ Identification of personal strengths and resources

___ Identification of environmental facilitators/barriers

___ Identification of specific demands of one occupational participation goal.

___ Participant was asked to identify what currently happens

___ Participant was asked Identify what the participant would like to happen

___ Participant was asked explore barriers and bridges to enabling performance

___ Participant was asked identify his/her needs in planning and taking actions to

achieve goals.

e) Collaboration during analysis1

1 2 3 4

The Coach actively assumes the expert role for the majority of the interaction with the participant. The Caoch minimizes participant ideas

The Coach favors supplying knowledge or expertise and may not perceive or may ignore opportunities for mutual problem solving.

The Coach incorporates client’s goals, ideas and values but does not do so consistently. The Coach may sacrifices some opportunities for mutual problem solving in favor of supplying knowledge or

The Coach fosters collaboration and power sharing so that participant’s ideas impact the analysis The Coach explicitly identifies the participant as the expert

xxv © Dorothy Kessler Jan 31, 2013

Participant #________ Session #_______ Date______________

expertise

f) Collaboration during Planning1

1 2 3 4 The Coach actively assumes the expert role for the majority of the interaction with the participant. The Caoch minimizes participant ideas

The Coach favors supplying knowledge or expertise and may not perceive or may ignore opportunities for mutual planning

The Coach incorporates client’s goals, ideas and values but does not do so consistently. The Coach may sacrifices some opportunities for mutual planning in favor of supplying knowledge or expertise

The Coach fosters collaboration and power sharing so that participant’s ideas impact the session The Coach explicitly identifies the participant as the expert

___ Education

a) Education was provided in the following areas: ___ Health Conditions and Impairments ___ Specialized Strategies ___ Community Resources and Entitlements ___ Typical Development ___ Teaching and Learning Strategies

b) The Content of the educations was:

1 2 3 4 General, not specific or responsive to participant’s needs.

Mostly general, with some content related to participant’s goals

Related to identified goals of the participant but not consistently responsive to participant’s concerns.

Individualized for participant’s needs and goals and responsive to the concerns of the participant

xxvi © Dorothy Kessler Jan 31, 2013

Participant #________ Session #_______ Date______________

Rate the following general items Focus of approach:

1 2 3 4 The approach focussed on participant’s problems and barriers to solutions. There was minimal discussion about strengths and finding solutions

The primary focus was on problems and barriers with occasional discussion of strengths and solutions

The primary focus was on strengths and finding solutions to problems with occasional focus on problems and barriers.

While problems and barriers were acknowledged, the approach focussed on participant’s strengths ( knowledge, skills, experience, resources and intuition) and on solutions to identified problems

Empathy1:

1 2 3 4 The Coach gives little or no attention to the client’s perspective. Seeks factual information. Does not attempt to understand the client’s Perspective. The participant maintains a distance from the Coach and provides limited factual and superficial information

The Coach makes occasional efforts to explore the client’s perspective. The coach attempts to understand the participant’s perspective are shallow may detract from the participant’s true meaning. The participant openly communicates factual information the Coach but does not elaborate or share feelings in responses

The Coach makes active and repeated efforts to understand the participant’s point of view. The coach encourages minimal elaboration and understanding is mostly limited to explicit content. The participant begins to elaborate on thoughts and share feelings

The Coach shows evidence of deep understanding of participant’s point of view, not just for what has been explicitly stated but what the participant means but has not yet said. The Coach attempts to put self in the participant’s shoes and encourages elaboration. The participant freely elaborates on thoughts and shares deeper feelings

xxvii © Dorothy Kessler Jan 31, 2013

Participant #________ Session #_______ Date______________

Autonomy/Support1:

1 2 3 4 The Coach discourages participant’s perception of choice The coach is not genuine when discussing participant’s choice and implies that external consequences remove choice

The Coach does not deny options or choice, but makes little effort to actively instill it The coach does not bring up the topic of choice in the session and may dismiss it when raised by the participant

The Coach is accepting and supportive of participant autonomy. The Coach explores options genuinely with participant but provides minimal support to take action to pursue control

The Coach is proactive in eliciting comments from the participant that lead to a greater perceived choice regarding the goal achievement. The Coach provides multiple opportunities to discuss participant’s options and ability to control if s/he does not respond at first attempt

1 Adapted from: Revised Global Scales: Motivational Interviewing Treatment Integrity 3.1.1 (MITI 3.1.1) T.B. Moyers, T. Martin, J.K. Manuel, W.R. Miller, & D. Ernst University of New Mexico Center on Alcoholism, Substance Abuse and Addictions (CASAA) January 2010

xxviii © Dorothy Kessler Jan 31, 2013

Appendix G

CONSENT TO PARTICIPATE IN RESEARCH

Teachers’ perception of their own performance, satisfaction, and self-efficacy to support the self-regulation of their students: a pilot study

You are asked to participate in a research study conducted by Caroline Hui under the supervision of Dr. Laurie Snider from the School of Physical and Occupational Therapy at McGill University. You may contact Ms. Hui at 450-242-2186 or caroline.hui@mail.mcgill.ca or Dr. Snider at 514-398-5863 or laurie.snider@mcgill.ca.

If you have any questions or concerns about this research, please feel free to contact the Graduate Program Director at the School of Physical and Occupational Therapy McGill University: Dr. Eva Kehayia at 14-398-5867 or eva.kehayia@mcgill.ca.

PURPOSE OF THE STUDY

This research study wishes to investigate to what extent a one day educational workshop and weekly follow-up coaching will help teachers improve their perception of their performance, their satisfaction and their confidence to support students with difficulties with self-regulation. Teachers are faced with teaching a wide variety of students, many students having particular behaviours. Poor self-regulation can lead to challenging behaviours which can be difficult to manage in the classroom. Teachers may feel stress and dissatisfaction with their performance in dealing with these challenging behaviours.

The intervention in this research study is a one day workshop on the impact of self-regulation on attention, behaviour and an overview of the Alert Program®1. As well, eight individual weekly follow-up coaching sessions are part of the intervention to support participating teachers in order to improve their perception of their performance, their satisfaction and their confidence to support students with self-regulation. Can an occupational therapist using coaching methods help them?

PROCEDURES

If you volunteer to participate in this study, this is the format of how it would take place:

1. INITIAL MEETING: You will be contacted to set up a semi-structured interview in order to obtain base-line information. You will be asked to rate your performance and

1 The Alert Program®: How does your Engine Run? was developed by Occupational Therapists Mary-Sue Williams and Sherry Shellenburger (1997) to teach teachers and children that their bodies are like engines: sometimes they run on high, sometimes they run on low but in class we need them to run just right in order to learn. Sensory motor strategies are taught to change the speed of one’s engine to learn more attentively.

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satisfaction of dealing with challenging behaviours and poor self-regulation with the Canadian Occupational Performance Measure. Goal Attainment Scaling will also be used to determine scale your specific goals regarding self-regulation in the classroom. A few questions will be asked about your knowledge of self-regulation, sensory motor strategies and the Alert Program®. You will complete a short form to provide information on years of experience, grade taught, and other pertinent data. This interview will be audiotaped and all information collected will be kept confidential in a locked file. It will be held at your school and will take approximately 90 minutes.

2. OBSERVATION: An observation in each of the participant’s classroom during the most difficult time of the day (60 minutes) will be done prior to the one day workshop. The classroom observation is to gain information on the types of students and behaviours the teacher is faced with in order to better understand what the teacher is experiencing.

3. ONE DAY WORKSHOP: Within two weeks of the initial interview and classroom observation, a one day workshop will be held with all participants. It will take place at an Eastern Township School Board location convenient for most participants. Snacks and lunch will be provided.

4. INTERVENTION: Weekly individual sessions with the participants will be held at their school or via Skype for eight weeks. These sessions, with the occupational therapist, will be guided by occupational performance coaching to help the participant meet their goals. These will last approximately 60 minutes and are scheduled not to interfere with teacher’s class time. Participants will have the possibility of a self-initiated contacted with the researcher by telephone or by email an additional time should they need more coaching during the week.

5. RECORDING: Participants will have a daily log to fill out to indicate the type of strategy student’s use for self-regulation and the frequency of its use. It is a simple form not requiring more than a few minutes to check off.

6. SECOND MEETING: At the end of eight weeks, a second semi-structured interview will be done within two weeks. This will be similar to the initial meeting. It is scheduled to last approximately 60-90 minutes. Like the initial meeting, this meeting will be audiotaped and all information collected will be kept confidential in a locked file.

7. OBSERVATION: A classroom observation will take place within one week of the last individual session.

8. FINAL MEETING: Eight weeks after the second semi-structured interview is completed,

xxx

A final meeting will take place. The same measures as in the other two interviews will be done. This pilot study will be enriched by gathering information on whether change is maintained. This follow-up will be scheduled for 60 minutes. Like the other two

data

collection meetings, this meeting will be audiotaped and all information collected will be kept confidential in a locked file.

9. RESEARCH FINDINGS: All research findings will be made available to the each participant about their results.

10. Participants will be involved in this research study for approximately four months from the initial meeting to the final meeting. See figure 1.

POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY

Many teachers have students with challenging behaviours in their classroom. Teachers participating in this research study will have the benefit of learning new strategies to help their students and help them gain confidence in using their new skills. The participant will have free training on how to use sensory motor strategies with their students and benefit from eight weeks of individual follow up with an occupational therapist to coach them in meeting their goals and needs regarding challenging behaviours in their classroom.

On a more global scale, the results of this study will impact how school-based occupational therapists deliver their services in order to benefit teachers and their students and provide us with a better understanding on how to share knowledge.

Recruitment and consent

Pre-intervention measures completed and classroom observation

Intervention- one day workshop + eight weeks of weekly sessions

Post-intervention measures completed and classroom observation

Within one week of end of intervention

Begins within two weeks of data collection

Figure 1. Procedures

Maintenance measures completed

8 weeks after post-intervention measures completed

Measures at Time 1 Measures at Time 2 Measures at Time 3

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There are no particular risks with delivery of this information.

PARTICIPATION AND WITHDRAWAL

The participant chooses whether to be in this study or not. The participant has the right to ask questions at any time. If you volunteer to be in this study, you may withdraw at any time without consequences of any kind. You may exercise the option of removing your data from the study.

CONFIDENTIALITY

Every effort will be made to ensure confidentiality of any identifying information that is obtained in connection with this study.

Each participant will be assigned a number to ensure that their name not be used. Their numbers, not their names, will appear on all questionnaires they complete. No party other than the primary researcher will know what names correspond to what number. The data collected will not be used for any other reason than this research study.

The semi-structured interviews to gain more information on knowledge of self-regulation and strategies used to deal with challenging behaviours in the classroom will be audio-taped. Transcripts will be made of the information and will be reviewed by the participant to ensure the information is correct. Participants may edit the transcripts as needed. Audiotapes and transcripts will be destroyed five years after completion of the data collection.

SIGNATURE OF RESEARCH PARTICIPANT

I have read the information provided for the study: Teachers’ perception of their own performance, satisfaction, and self-efficacy to support the self-regulation of their students: a pilot study as described herein. My questions have been answered to my satisfaction, and I agree to participate in this study. I have been given a copy of this form.

______________________________________

Name of Participant (please print)

______________________________________ ______________

Signature of Participant Date

SIGNATURE OF WITNESS

______________________________________ Name of Witness (please print) ______________________________________ _______________ Signature of Witness Date

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Appendix H

Baseline measures intake

Sign consent form

Explain role of occupational therapist

Fill out the intake form

Questions to guide the semi-structured interview:

• If we take a look at your day with your students, tell me what you feel is difficult in terms of dealing with their behaviours (can give a few examples only if they have trouble finding their own: transition times with students, afternoon after recess…).

• What would you like to change? Improve? • What expectations do you feel you must meet with the students but are unable or feel

dissatisfied?

Guide them to find four areas they would like to change

Rate performance and satisfaction on difficulties/problems they identified

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Appendix I

Additional information needed from participants (date)

Participant information:

Name (left blank- participant number inserted)________________________________________

School:_______________________________________________________________________

Grade taught:__________________________________________________________________

Number of boys in the class______________Number of girls in the class___________________

Number of special needs students in the class?_______How many are boys?____ How many are girls?_________________________________________________________________________

In general, students’ misbehaviours are: ______ mild _____moderate _____severe

Years of experience:_____________________________________________________________

Teaching diploma was obtained from:_______________________________________________

Administrative staff is supportive ____all the time ____sometimes ___not at all

I have done previous workshops on self-regulation ________no ____________yes If yes, please state with who and when ____________________________________________________

Please describe what you understand about self-regulation: ______________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

Please list what you are presently doing to address challenging behaviours in the classroom:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Email address:______________________________

All information provided remains confidential and will be used for the sole purpose of this research project.

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Appendix J

Class Observation

Date: _________________ Time beginning/end: _________________

Participant ID: __________________________________

Task/activity observed: ___ individual work ____ group instruction _____ small group activity

____whole class activity ____other (specify) ____________

Subject: ______Math _____ English _____ French _____Social Science _____ERC _____

_____Other (specify)__________

General classroom behaviour will be observed for a slice of 20 minutes using the items on Teacher’s Report Form: (note time initial and end), check those that apply and can comment.

Start time___________________ end time____________________

o Acts too young for his/her age o Hums or makes other odd noises in class o Argues a lot o Fails to finish things he/she started o There is very little that he/she enjoys o Defiant, talks back to staff o Bragging, boasting o Can’t concentrate, can’t pay attention for long o Can’t get his/her mind off certain thoughts/obsessions o Can’t sit still, restless, or hyperactive o Clings to adults or too dependent o Confused or seems to be in a fog o Cries a lot o Fidgets o Cruelty, bullying, or meanness to others o Daydreams or gets lost in own thoughts o Deliberately harms self or attempts suicide o Demands a lot of attention o Destroys his/her own things o Destroys property belonging to others o Difficulty following directions o Disobedient at school o Disturbs other pupils o Doesn’t get along with other pupils o Doesn’t seem to feel guilty after misbehaving o Easily jealous

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o Breaks school rules o Fears certain animals, situations, or places other than school o Fears going to school o Fears he/she might think or do something bad o Feels he/she has to be perfect o Feels or complains that no one loves him/her o Feels others are out to get him/her o Feels worthless or inferior o Gets hurt a lot, accident-prone o Gets in many fights o Gets teased a lot o Hangs around with others who get in trouble o Hears sounds or voices that aren’t there o Impulsive or acts without thinking o Would rather be alone than with others o Lying or cheating, bites fingernails o Nervous, high strung, or tense o Nervous movements or twitching o Overconforms to rules o Not liked by other pupils o Has difficulty learning o Too fearful or anxious o Feels dizzy or lightheaded o Feels too guilty o Talks out of turn o Overtired without good reason o Overweight o Physical problems without known medical cause o Physically attacks people o Picks nose, skin, or other parts of body o Sleeps in class o Apathetic or unmotivated o Poor school work o Poorly coordinated or clumsy o Prefers being with older children or youths o Prefers being with younger children o Refuses to talk o Repeats certain acts over and over; complusions o Disrupts class discipline o Screams a lot o Secretive, keeps things to slef o See things that aren’t there o Self-conscious or easily embarrassed o Messy work o Behaves irresponsibly o Showing off or clowning

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o Too shy or timid o Explosive and unpredictable behavior o Demands must be met immediately, easily frustrated o Inattentive or easily distracted o Speech problem o Stares blankly o Feels hurt when criticized o Steals o Stores up too many things he/she doesn’t need o Strange behaviour o Strange ideas o Stubborn, sullen, or irritable o Sudden changes in mood or feelings o Sulks a lot o Suspicious o Swearing or obscene language o Talks about killing himself o Underachieving, not working up to potential o Talks too much o Teases a lot o Temper tantrum or hot temper o Seems preoccupied with sex o Threatens people o Tardy to school or class o Smokes, chews, or sniffs tobacco o Fails to carry out assigned tasks o Truancy or unexplained absences o Underactive, slow moving, or lacks energy o Unhappy, sad, or depressed o Unusually loud o Uses alcohol or drugs o Overly anxious to please o Dislikes school o Is afraid of making mistakes o Whining o Unclean personal appearance o Withdrawn, doesn’t get involved with others o Worries

Disposition of class (sketch it out):

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Sensory motor strategies available in class (indicate how many if appropriate):

____ therapy ball ____disc o sit _____ quiet corner _____rocking chairs _______therabands on legs of chair _____ water bottles ______fidgets _____time timer _____music ______ gum _____straws ______noise reducing head phones _____ alternate lighting _____exercise bicycle _______chin up bar ______personal desk screens _______T-stools _______weighted objects _______other (specify)________________________________________________________

Observation of teacher’s stratgies

Intervention of teacher

Physical cue Requests student leave class Ignores Changes student place Provides sensory motor strategy

Places note on board for mis-behaving

Leaves classroom Requests help from other adult

Provides object to fidget Raises voice Verbal reprimand Uses Engine vocab. with students

Provides positive reinforcement

Changes tone of voice Provides a visual cue Shuts the light Turns on/off music Other

Comments/notes: ______________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Appendix K Outline of workshop

Tools to Improve Attention and Self-regulation for Students in the Classroom

One day workshop for teachers (phase 1 of intervention for research project)

8:30-8:45 Welcome, introductions

8:45-9:15 Objectives of the day and case study (Mrs. Wood), discussion on what they can be interpreted from two images (Antoine in line and Simon lying on his desk)

9:15-10:00 Definitions of terminology sensory processing, vestibular, proprioception, visual, tactile, olfactory, auditory and tactile (concrete examples of each use sand paper and feather to illustrate tactile issues)

10:00-10:30 Processing issues that can occur, what behaviours can be noted in class, Taylor and Trott triangle, hands on examples of difficulties (feet off floor, non-dominant hand and write name)

10:30-10:45 Break

10:45-11:15 Video of Learning about Learning Disabilities and brief discussion

11:15-11:45 Self-regulation – programs available, projects in BC and Winnipeg

11:45-12:45 Lunch (included)

12:45-1:30 Overview of the Alert Program (history, vocabulary defined: arousal, self-regulation, low engine, just right engine, high engine) brief how to use program with students, checklist and game that helps participants learn about their own self-regulation strategies

1:30 -2:30 Strategies for the classroom: touch, proprioception, oral motor, movement, visual, auditory, olfactory (video of classroom examples)

2:30-2:45 Break

2:45-4:15 Strategies continued, self-regulation, return to case study, questions

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Appendix L

Learning Outcomes of Objectives

General Specific Knowledge dimension Level of Thinking

1. Understand the impact that sensory processing has on self-regulation.

1.1 Define the terminology associated with sensory processing.

1.2 Identify how sensory processing impacts behaviour.

1.3 Identify observable behaviours of students with difficulties processing input in vestibular, tactile, auditory, and visual systems.

Factual Conceptual Factual

Remember Understand Remember

2. Understand the

terminology related to self-regulation.

2.1 Define the terminology associated with self-regulation.

2.2 Explain how sensory processing affects self-regulation.

Factual Conceptual

Remember Understand

3. Interpret personal

self-regulation

3.1 Identify own strategies to self-regulate.

3.2 Identify ways to change their alertness level.

Metacognition Conceptual

Evaluate Apply/Analyze

4. Understand the role self-regulation plays on student attention, learning, and behaviour.

4.1 Explain how it can impact attention, behaviour, and academic performance.

4.2 Explain the difference between students with special needs vs neurotypical students’ self-regulation.

4.4 Differentiate situations when self-regulation be can an issue vs a behavioural issue.

Conceptual Conceptual Conceptual

Understand Apply Analyze

5. Apply sensory motor strategies in the classroom to help students.

5.1 Describe a behavioural approach.

5.2 Describe a cognitive approach.

5.3 Describe a sensory motor approach.

5.4 Identify specific strategies to use in group situations.

5.5 Utilize new ways to improve attention and behaviour.

Factual Factual Factual Procedural Procedural

Remember Remember Remember Apply Create

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Knowledge Dimension

Factual

Conceptual

Metacognition

Procedural

Level of Thinking

Remember

Understand

Apply

Analyze

Evaluate

Create

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Appendix N References for workshop

Ayres, A.J. (1972). Sensory Integration and the Child. Los Angeles, CA: Western Psychological Services. Ayres, A.J. (1989). Sensory Integration and Praxis Tests. Los Angeles, CA: Western Psychological Services. Baker, A.E.Z., Lane, A., Angley, M.T., & Young, R.L. (2008). The relationship between sensory processing patterns and behavioural responsiveness in autistic disorder: A pilot study. Journal of Autism and Developmental Disorder. 39. 867-875. Barnes, K. J., Vogel, K. A., Beck, A. J., Schoenfeld, H. B., & Owen, S. V. (2008). Self-regulation strategies of children with emotional disturbance. Physical & Occupational Therapy in Pediatrics, 28(4), 367-385. Barnett W.S, Jung, K., Yarosz, D., Thomas, J., Hornbeck, A., Stechuk., R., & Burns, S. (2008). Educational effects of the Tools of the Mind curriculum: A randomized trial. Early Childhood Research Quarterly. 23:213-313. Beauchemin J, Hutchins TL, Patterson F. (2008). Mindfulness meditation may lessen anxiety, promote social skills, and improve academic performance among adolescents with learning disabilities. Complementary Health Practice Review. 13(1):34-45. Benbow, M., Hanft, B, & Marsh, D. (1992). Handwriting in the Classroom : Improving Written Communication. In Royeen, C.B. (Ed), AOTA Self Study Series Classroom Applications for School Based Practice p. 21. Rockville, MD: AOTA, Inc. Ben Sasson, A., Carter, A., & Briggs Gowan, M. (2010). The development of sensory over-responsivity from infancy to elementary school. Journal of Abnormal Child Psychology, 38(8), 1193-1202. Ben-Sasson, Ayelet et al. (2008). A Meta-Analysis of Sensory Modulation Symptoms in Individuals with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders 39: 1-11. Blanche E, Reinoso G, Chang M, Bodison S. (2012). Proprioceptive processing difficulties among children with autism spectrum disorders and developmental disabilities. The American Journal of Occupational Therapy. 66(5):621-4. Brewer, C. & Campbell, D. (1991). Rhythms of Learning, creative tools for developing lifelong skills. Tuscon, AZ: Zephyr Press. Buchanan, R., Lust, C., Donica, D., Painter, J., Trjillo, L. (2011). Implementing the Alert Program® in a kindergarten curriculum using the Response to Intervention (RtI) method. Ph. D. 1505388. East Carolina University. Greenville, NC. Bundy, A.C., Shelly J.L., & Murray E.A. (2002). Sensory Integration- Theory and Practice, 2nd Ed. Philadelphia : F.A. Davis Company. Cahill, S.M. (2006). Classroom management for kids that won’t sit still and other ‘bad apples.” Teaching Exceptional Children Plus, 3(1). CADDRA Canadian ADHD Practice Guidelines Third Edition (2011)

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Cawn, S. & Osten, B. (2005) A View from the Floor: Integrating the Neurological and Emotional Development of the Child. Conference, class notes. Chiodo, P.G. (2010). Outcomes on attention with an implementation of the Alert Program in school-based setting. Ph.D. Thesis, Chatham University, Pittsburg, PA. Degangi, G. & Greenspan, S. (1989) Test of Sensory Functions in Infants. Los Angeles, CA: Western Psychological Services. Degangi, G. & Berk, R. (1983) DeGangi-Berk Test of Sensory Integration. Los Angeles, CA: Western Psychological Services. Doidge, Norman. (2007). The brain that changes itself. NY, New York: Penguin Books. Dunn, Winnie (1999). Sensory Profile. San Antonio, TX: Pearson Assessments. Fedewa, A., & Erwin, H. (2011). Stability balls and students with attention and hyperactivity concerns: implications for on-task and in-seat behavior. The American Journal of Occupational Therapy, 65(4), 393-399. Frick, Sheila OTR; Colleen Hacker, OTR; Genevieve Jereb, OTR (September 2000). Treatment perspectives for sensory modulation disorders. Conference-Atlanta, GA. Frick, S., Cool, S., & Kawar, M. (December 1999). Full Inclusion- Vision and Hearing in Sensory Integration Practice. Vestibular-Auditory-Visual Triad. Conference-Tampa, FL. Funston, S. & Ingram, J. (1994). A Kid’s Guide to the Brain. Toronto, ON: Greey de Pencier Books. Gere, D.R., Capps, S.C., Mitchell, W., & Grubbs, E. (2009). Sensory sensitivities of gifted children. The American Journal of Occupational Therapy, 64, 288-295. Gordon, David & Steve. (1998). Sacred Spirit Drums. Sequoia Records. Earth Vision Music, Inc. Greenspan, M.D., S. & Wieder, S., PhD. (1998) The Child with Special Needs. Reading, MA: Perseus Books. Hannaford, C., Ph.D (1995). Smart Moves- Why Learning is not all in your Head. Arlington, VA: Carla Hannaford. Henry, Diana (1997) Tools for Teachers (videotape). Pheonix, Az: Henry OT Services Inc. Henry, Diana (2004) SI Tools for Teens: Strategies to Promote Sensory Processing. Pheonix, AZ: Henry OT Services Inc. Jereb, Genevieve. (2003) Say G’Day. Genevieve Jereb. Gellybean Records. www.genjereb.com Jereb, Genevieve. (2004). Cool Bananas. Genevieve Jereb. Gellybean Records. www.genjereb.com KidzJamz. (2003) Apricot Jamz. Happy Turtles, LLC. www.kidzjamz.com

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Kinnealey M, Pfeiffer B, Miller J, Roan C, Shoener R, Ellner M. (2012). Effect of classroom modification on attention and engagement of students with autism or dyspraxia. The American Journal of Occupational Therapy. 66(5):511-9. Kuypers, L. (2011). The Zones of Regulation. San Jose, CA: Social Thinking. Miller, Lucy Jane, Ph.D. OTR (2006). New York, NY: G.P. Putnam`s Sons. Sensational Kids- Hope and Help for Children with Sensory Processing Disorder Minnesota OT Association Learning about Learning Disabilities (videotape). Mulligan, S. (2001). Classroom strategies used by teachers of students with attention deficit hyperactivity disorder. Physical & Occupational Therapy in Pediatrics, 20(4), 25-44. Murray-Slutsky, Carolyn, MS, OTR & Paris, Betty A., PT M.Ed. (2005). Is it Sensory or Behavior? San Antonio, TX: PsychCorp: Harcourt. Occupational Therapy Now September/October 2009. Special Issue: Sensory Processing and Occupation: Their intersection and impact on everyday life. Vol. 11-5. Oetter P, Richter, E. & Frick, S. (1988) M.O.R.E. integrating the mouth with sensory and postural function. (2nd ed) USA: PDP Press. Parham, D., Ecker, C., Miller Kuhaneck, H., Henry, D., Glennon, T. (2007). Sensory Processing Measure. Los Angeles, CA: Western Psychological Services. Pfeiffer, B., Henry, A., Miller, S., & Witherell, S. (2008). Effectiveness of Disc 'O' Sit cushions on attention to task in second-grade students with attention difficulties. The American Journal of Occupational Therapy, 62(3), 274-281. Polatajko, H., Mandich, A. (2004). Enabling Occupation in Children: The Cognitive Orientation to Daily Occupational Performance (CO-OP) Approach. Ottawa, ON: CAOT Publications. Porges S. (2003). The Polyvagal Theory: Phylogenetic contributions to social behavior. Physiology & behavior. 79(3):503-13. Reid, R., Trout, A., & Schartz, M. (2005). Self-regulation interventions for children with Attention Deficit Hyperactivity Disorder. Exceptional Children. 71. 361-367 Semple RJ, Lee J, Rosa D, Miller LF. (2010). A randomized trial of mindfulness-based cognitive therapy for children: promoting mindful attention to enhance social-emotional resiliency in children. Journal of Child & Family Studies. 19(2):218-29. Shanker, S. (2012). Calm, Alert and Learning. Don Mills, ON: Pearson. Shaw, W. (1998). Biological Treatments for Autism and PDD. William Shaw, PhD: USA. Shellenberger S. & Williams M. (March 1998). How does your engine run? The alert program for self regulation. conference-Tampa.

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Shellenberger S. & Williams M. (October 2011). How does your engine run? The alert program for self regulation. conference-Orford, QC. Shellenberger S. & Williams M. (1998) How does your engine run? The alert program for self regulation. Albuquerque, Therapy Works, Inc. Schilling, D.L. & Schwartz, I.S. (2004). Alternative seating for young children with autism spectrum disorder: effects on classroom behaviour. The Journal of Autism and Developmental Disorders, 34(4), 423-432. Schilling, D.L., Washington, K., Billingsley, F.F., & Deitz, J. (2003). Classroom seating for children with attention deficit hyperactivity disorder: therapy balls versus chairs. The American Journal of Occupational Therapy, 57(5), 534-541. SII (1986) A parent’s guide to understanding sensory integration. Torrance, CA: Sensory Integration International. Stephenson, Jennifer; Carter, Mark (2008) The Use of Weighted Vests with Children with Autism Spectrum Disorders and Disabilities. Journal of Autism and Developmental Disorders (2009). 39:105-114. Trott, M.C., Laurel, M.K., & Windeck, S.L. (1993). Sensabilities: Understanding sensory integration. Tucson, AZ: Therapy Skill Builders. Tucha L, Simpson W. (2011). The role of time on task performance in modifying the effects of gum chewing on attention. Appetite. 56(2):299-301. Tucha L., Simpson, W., Evans, L., Birrel, L. Sontag, T.A., Lange, K.W., Tucha, O. (2010). Detrimental effects of gum chewing on vigilance in children with attention deficit hyperactivity disorder. Appetite. 55(3):679-84. Verret, Claudia (2012). Doctoral Thesis: L’activité physique est bénéfique pour les enfants qui ont un TDAH. http://www.nouvelles.umontreal.ca/recherche/sciences-de-la-sante/20120604-lactivite-physique-est-benefique-pour-les-enfants-qui-ont-un-tdah.html. Wehmeyer M.L., Schwartz, M. (1997) Self-determination and positive adult outcomes: A follow-up study of youth with mental retardation or learning disabilities. Exceptional Children. 63:245-55. Wilbarger, P. & Wilbarger, J. (1991) Sensory defensiveness in children aged 2-12. Santa Barbara, Avanti Educational Programs. (the term “sensory diet” was coined by P. Wilbarger) Wilbarger, P. & Wilbarger, J. (2004) Sensory Defensiveness: A comprehensive treatment approach. conference- Montreal. Winsler, A, Ducenne, L., & Koury, A. (2011). Singing one's way to self-regulation: The role of early music and movement curricula and private speech. Early Education and Development. 22(2):274. Wolfe, D.E. & Noguchi, L.K. (2009). The use of music with young children to improve sustained attention during a vigilance task in the presence of auditory distractions. The Journal of Music Therapy, 46(1), 69-82. Worthen, E. (2010). Sensory-based interventions in the general education classroom: A critical appraisal of the topic. Journal of Occupational Therapy, Schools, and Ealry Intervention. 3:1, 76-94.

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Wyman P, Cross W, Hendricks Brown C, Yu Q, Tu X, Eberly S. (2010). Intervention to strengthen emotional self-regulation in children with emerging mental health problems: proximal impact on school behavior. Journal of Abnormal Child Psychology. 38(5):707-20. Yack, E., Sutton, S. & Aquilla, P. (1998). Building Bridges through Sensory Integration. Weston, ON.

Suggested resources Anderson, E. & Emmons, P. (1996). Unlocking the Mysteries of Sensory Dysfunction. Arlington, TX: Future Horizons, Inc. Brewer C. & Campbell D. (1991). Rhythms of Learning. Tuscon, AZ: Zephyr Press, Inc. Grandin, Temple. (1986). Emergence: Labeled Autistic. Novato, CA: Arena Press. Greenspan, M.D., S. & Wieder, S., PhD. (1998) The Child with Special Needs. Reading, MA: Perseus Books. Haldy, M. & Haack, L. (1995). Making it Easy, Sensorimotor Activities at Home and School. Tuscon, AZ: Therapy Skill Builders. Henry, D. (1998). Tools for Teachers. Phoenix, AZ: Henry Occupational Therapy Services, Inc. Kranowitz, C.S., M.A. (1998) The Out of Sync Child. New York, NY: Skylight Press and Carol Stock Kranowitz. Kranowitz, C.S., M.A. (2003) The Out of Sync Child has Fun. New York, NY: The Berkley Publishing Corp. Kranowitz, C.S, Szkut, S., Balzer-Martin, L., Haber, E. & Sava, D.I. (2003). Answers to Questions Teachers Ask About Sensory Integration. Las Vegas, NV: Sensory Resources. Miller, Lucy Jane, Ph.D. OTR (2006). New York, NY: G.P. Putnam`s Sons. Sensational Kids- Hope and Help for Children with Sensory Processing Disorder Murray-Slutsky, Carolyn, MS, OTR & Paris, Betty A., PT M.Ed. (2005). Is it Sensory or Behavior? San Antonio, TX: PsychCorp: Harcourt. Shellenberger S. & Williams M. (2001). Take Five, Staying Alert at Home and at School. Alburquerque, NM: Therapy Works, Inc.

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Appendix O Tools to Improve Attention and Self-Regulation for Students in the Classroom

Workshop Feedback Form January 29th 2013

We would greatly appreciate your feedback. Please take a few minutes to complete this questionnaire and use the space provided for additional comments. Please circle the appropriate number according to the following: 5-strongly agree 4-agree 3-no comment 2-disagree 1-strongly disagree The material presented was clear and well organized: 5 4 3 2 1 The audio-visual materials used were pertinent and helpful in better understanding the topic: 5 4 3 2 1 The materials covered met with my expectations: 5 4 3 2 1 This conference should be recommended to others: 5 4 3 2 1 The learning objectives were met: 5 4 3 2 1 The conference was well organized (notes, refreshments provided…) 5 4 3 2 1 (comments): _______________________________________________________________ What did you like most about this workshop? What would you have liked to have been different? _________________________________________________________________ _________________________________________________________________________ Do you feel able to implement the information from this workshop in your setting when you return to it? ________________________________________________________________ Is there anything else you would like the speaker to know? __________________________ __________________________________________________________________________ Additional Comments: __________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ Thank you for your feedback!

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Appendix P

Outline for Weekly Occupational Performance Coaching (OPC) sessions

OPC was developed for therapists to work with parents but since it is an occupation-centered intervention, it can also be used with teachers. OPC is grounded in enabling and has an end goal of improving occupational performance. The principles of OPC are:

• Better congruence between person, task, and environment encourages learning and enablement.

• Teachers have knowledge and opinions that are essential for planning effective solutions. • Knowing the needs of the teachers is more important than knowing which strategies will

best enable performance. • The main outcome is occupational enablement.

To assist teachers in achieving their goals, there are three enabling domains:

A) Emotional domain- used to acknowledge the teacher’s intrapersonal challenge in being the change agent within one’s context and it aims to build the therapeutic relationship. Listen without judgment and validate their experience. This allows the therapist to gather information about their interpretation of performance, motivators for change, learning needs in implementing change and previous successes in enabling performance. Empathise genuinely when needed, this helps to build trust. Reframe their perceptions by paraphrasing of offering alternative interpretations. Ex: Stating that a child falling off his chair because of poor postural control and decreased awareness of his body leads to teachers to different strategies. Reframing the behaviour of falling off is chair as a motor skill issue guides the teacher. Guide “lead from behind,” encourage teachers to make choices about specific actions. Minimize direct advice giving since this is not conducive to independent future problem solving. Encourage by commenting on specific progress, insights, actions or new learning.

B) Information exchange domain- a two-way process whereby the teacher shares information (ex: about what they have tried, what works) which is equally important to what the therapist shares (ex: sensory processing information). The information shared by the therapist is not the first step; it occurs when there is a need in order to facilitate the

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teachers’ enablement. The information is exchanged through a collaborative performance analysis (CPA) by the teacher and therapist. Collaborative performance analysis:

1- Identify what currently is happening (student’s actions, teacher’s actions, background and immediate environment, strategies tried, performance outcome)

2- Identify what teacher would like to happen (student’s actions, teacher’s actions, background and immediate environment, strategies tried, performance outcome)

3- Explore barriers and bridges to enabling performance (in the students (motivation, knowledge, ability?), in the tasks (steps, sequences, standard?), in the environment (physical, social?)

4- Identify teacher’s needs in implementing change (motivation, interpretation, learning needs)

(Collaborative Performance Analysis- Slight modification of Figure 3.2 from CPA (label of parent changed to teacher), Graham, 2010)

Typical development: Explain as needed. Teachers have experience in this area but may need reminder that diagnosis of student may affect typical development.

Health conditions and impairments: Share information as needed; may provide them with information specific to the diagnosis of their student if needed.

Teaching and learning strategies: Share information about what is working in the class for self-regulation and what is not working. Review reasons why and problem solve together if not self-regulation strategies working.

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Specialised strategies: Since self-regulation strategies are the main focus, some other specialized strategies may be mentioned but need to be documented. This is not the focus of this study.

Community resources and entitlements: In this case, teachers can find support from other staff members or administration. May share specific websites they can visit for support and more information (www.ateachabout.com, www.alertprogram.com)

C) Structured problem-solving domain- clear sequence of steps that guide the overall

direction of interactions. The teacher is informed that together they are working to achieve the teacher’s goals using the Person, Environment, Occupation (PEO) Model (Law et al, 1996).

(Graham, 2010) Set goal: VERY IMPORTANT, goals are set on the table at each session in order to maintain focus. Explore options: what can be done, problem solve together Plan action: what will be done that week Carry out plan Check performance Generalize

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Figure 10-1 Three enabling domains. page 203 (Graham & Rodger, 2010)

Key points:

• The therapist, through OPC, has the intent to facilitate goal performance and develop teacher’s skill in identifying ways to promote successful performance.

• Collaborative development of sustainable, enabling solutions to occupational performance is central focus through all OPC sessions.

• End all discussions with a brief summary and clarification and then review plan of action for next week.

This model serves to guide the eight weekly sessions between the teachers and the researcher.

SESSION 1- Explanation of occupational performance coaching (OPC). Overview of information gathered at intake 1 (pre-intervention). Discussion of goals and begin using collaboration performance analysis. Explain use of daily log notes. Make plans and review.

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SESSION 2- Review of goals and plan of past week. Review journal daily log

and problem solve as needed using emotional support, information exchange and the structured process of OPC. Return to information they learnt at workshop as needed.

Make plans for following week and review. SESSION 3- Use of OPC during session.

Review of goals and plan of past week. Review daily log notes. Discuss and problem solve as needed. Make plans and review. SESSION 4- Use of OPC during session.

Review of goals and plan of past week. Review daily log notes. Discuss and problem solve as needed. Make plans and review. SESSION 5- Use of OPC during session.

Review of goals and plan of past week. Review daily log notes. Discuss and problem solve as needed. Make plans and review. SESSION 6- Use of OPC during session.

Review of goals and plan of past week. Review daily log notes. Discuss and problem solve as needed. Make plans and review. SESSION 7- Use of OPC during session.

Review of goals and plan of past week. Review daily log notes. Discuss and problem solve as needed. Make plans and review. SESSION 8- Use of OPC during session.

Review of goals and plan of past week. Review daily log notes. Discuss and problem solve as needed. Overview. Confirm post1 intake date and time.

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PARTICIPANT NUMBER_________WEEK ____________ DATE ________________ Please indicate all strategies/tools that you used each day. If you use it one more than once during the am or the pm, please write it down every time. Thank you. Movement/heavy work

a) change type of seating b) structured recess c) group movement break d) individual movement break e) other _______________ (indicate which sensory motor strategy used)

Tactile a) fidgets b) other ________ (indicate which sensory motor strategy used)

Auditory a) music b) noise reducing headphones/earplugs c) change voice output (tone, rhythm, volume) d) other _________ (indicate which sensory motor strategy used)

Visual a)decrease visual input b) provide visual cues c) change lighting d) desk screens e) other __________ (indicate which sensory motor strategy used)

Oral-motor a) provide gum b) chewy adaptor for pencil c) breath work d) other _______ (indicate which sensory motor strategy used)

COMMENTS

MON am

pm

TUE am

pm

WED am

pm

THUR am

pm

FR I am

pm

Please do not hesitate to contact me if you have any questions or comments: caroline.hui@mail.mcgill.ca or call me at 450-242-2816.

Appendix Q D

aily Log for Participants

Appendix R IRB Approval

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Appendix S ETSB Approval

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Appendix T Permission request to principals

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Appendix U Recruitment letter to teachers

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PARTICIPANT 1 Goal 1: D.’s endurance Goal 2: Dy’s organisation Much less than expected outcome (-2)

Current performance in January: D writes 1-2 sentences for writing assignments with one verbal prompt.

Current performance in January: Dy begins a task within 9-11 minutes of having received the instructions with 2-3 physical or verbal prompts.

Somewhat less than expected outcome (-1)

D writes 3-4 sentences for writing assignments with one verbal prompt.

Dy begins a task within 7-8.59 minutes of having received the instructions with 2-3 physical or verbal prompts.

Expected level (0) Expected performance: D writes 5-6 sentences for writing assignments with one verbal prompt.

Expected performance: Dy begins a task within 5-6.59 minutes of having received the instructions with 2-3 physical or verbal prompts.

Somewhat more than expected level (+1)

D writes 7-8 sentences for writing assignments with one verbal prompt.

Dy begins a task within 5-6.59 minutes of having received the instructions with 1 physical or verbal prompts.

Much more than expected level (+2)

Beyond expectations: D writes 8 + sentences for writing assignments with one verbal prompt.

Beyond expectations: For Dy to begin a task within 1-4.59 minutes of having received the instructions with one physical or verbal prompt.

Goal 1: Concern: D is having difficulty attending to writing tasks due to his self-regulation issues. Present level: D is working only when prompted and he is pushed minimally; the work he does is accepted as it is. He is asked to write up 2 sentences and requires prompts to initiate the task. Goal 2: Concern: Dy has difficulty getting to task because of organisational issues and self-regulation issues. Present level: He requires three times more verbal cues that group to get started on task and it takes him about 10 minutes for him to get started.

Appendix V

Goal Attainment Scaling goals

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PARTICIPANT 1 Level of attainment

Goal 3: how to help B.

Much less than expected outcome (-2)

Current performance in January: Teacher rates her abilities to help B with his organisational skills and self-regulation at 2/10.

Somewhat less than expected outcome (-1)

Teacher rates her abilities to help B with his organisational skills and self-regulation at 5/10.

Expected level (0)

Expected performance: Teacher rates her abilities to help B with his organisational skills and self-regulation at 7/10.

Somewhat more than expected level (+1)

Teacher rates her abilities to help B with his organisational skills and self-regulation at 9/10.

Much more than expected level (+2)

Beyond expectations: Teacher rates her abilities to help B with his organisational skills and self-regulation at 10/10.

Goal 3: Concern: B has difficulty getting to a task due to poor organisational skills and self-regulation. Present level: Teacher rates her abilities to help B with his organisational skills and self-regulation at 2/10.

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PARTICIPANT 2 Goal 1: behaviours in the

classroom Goal 2: transitions

Much less than expected outcome (-2)

Current performance in January: Teacher rates her abilities in using sensory motor strategies in the classroom to deal with disruptive behaviours as less than 7/10 most of the time.

Current performance in January: Grade two students transition back to class last most of the week.

Somewhat less than expected outcome (-1)

Teacher rates her abilities in using sensory motor strategies in the classroom to deal with disruptive behaviours as 8/10 most of the time.

Grade two students transition back to class after the grade 1 students most of the week.

Expected level (0) Expected performance: Teacher rates her abilities in using sensory motor strategies in the classroom to deal with disruptive behaviours as 8.5/10 most of the time.

Expected performance: Grade two students transition back to class after the grade 3-4 class most of the week.

Somewhat more than expected level (+1)

Teacher rates her abilities in using sensory motor strategies in the classroom to deal with disruptive behaviours as 9/10 most of the time.

Grade two students transition back to class before the grade 3-4 class most of the week

Much more than expected level (+2)

Beyond expectations: Teacher rates her abilities in using sensory motor strategies in the classroom to deal with disruptive behaviours as 10/10 most of the time.

Beyond expectations: Grade two students transition back to class before the grade 3-4 class without fussing about what happened at recess most of the week.

Goal 1: Concern: Teacher uses Non Violent Communication (NVC) but disruptive behaviour continues to be present. Present level: Teacher rates her abilities in using sensory motor strategies in the classroom to deal with disruptive behaviours as 5/10. Students can be noisy in the classroom. There is no accessible Engine Room and the classroom has limited space.

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Goal 2: Concern: Transitions back to class from lunch or recess is difficult due to conflicts that occur during the time they are at lunch or recess. Present level: It takes them 10-15 minutes to get back to class. Classes tend to leave in order of grade level. Although they are grade two, they are usually the last class to leave.

PARTICIPANT 2 Level of attainment

Goal 3: loud in class Goal 4: anger and frustration

Much less than expected outcome (-2)

Current performance in January: R. can work without bothering his peers 40-59% of the time.

Current performance in January: Most students are able to express anger and frustration in meaningful and productive ways 50-64% of the time.

Somewhat less than expected outcome (-1)

R. can work without bothering his peers 60-79% of the time.

Most students are able to express anger and frustration in meaningful and productive ways 65-79% of the time.

Expected level (0)

Expected performance: R. can work without bothering his peers 80-89% of the time.

Expected performance: Most students are able to express anger and frustration in meaningful and productive ways 80-94% of the time.

Somewhat more than expected level (+1)

R. can work without bothering his peers 90% + of the time.

Most students are able to express anger and frustration in meaningful and productive ways 95% + of the time.

Much more than expected level (+2)

Beyond expectations: R. can work without bothering his peers 90% + of the time and maintains engaged to complete the task.

Beyond expectations: Most students are able to express anger and frustration in meaningful and productive ways 95% + of the time with minimal adult assistance.

Goal 3: Concern: R. is loud in the classroom. Present level: Teacher must remind him to be quiet several times in one period. He bothers his peers with his whistling and humming while working. He chews his clothing. Goal 4: Concern: Students frequently get angry and frustrated and express it inappropriately. Present level: Using NVC strategies such as the loving kindness circle but students continue to have outbursts at least once a day.

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PARTICIPANT 3 Goal 1: organisation of students Goal 2: attention in circle time Much less than expected outcome (-2)

Current performance in January: 41-60% of the students participate in the cleanup of the toys/materials with 5-6 prompts.

Current performance in January: Most students attend to and participate calmly in the lesson for less than one minute with prompts from teacher.

Somewhat less than expected outcome (-1)

61-80% of the students participate in the cleanup of the toys/materials with 5-6 prompts.

Most students attend to and participate calmly in the lesson for 1-2 minutes with 1 prompt from the teacher.

Expected level (0) Expected performance: 81-100% of the students participate in the cleanup of the toys/materials with 5-6 prompts.

Expected performance: Most students attend to and participate calmly in the lesson for 2-3 minutes with 1 prompt from the teacher.

Somewhat more than expected level (+1)

81-100% of the students participate in the cleanup of the toys/materials with 2-3 prompts.

Most students attend to and participate calmly in the lesson for 2-3 minutes without requiring prompts from the teacher.

Much more than expected level (+2)

Beyond expectations: 81-100% of the students participate in the cleanup of the toys/materials with 0-1 prompt.

Beyond expectations: Most students attend to and participate calmly in the lesson for 4-5 minutes without requiring prompts from the teacher.

Goal 1: Concern: Teacher feels disorganized and feels that this is not helping students be organized and independent, especially for cleaning up. Present level: Teacher forgets to involve students in picking up after activities. She ends up with a messy class room at the end of the day. When she does involve students in cleaning up, she must prompt them 5-6 times and even then, the cleanup is not adequate but she feels like she must move on to the next activity.

Goal 2: Concern: During calendar/circle time, students move around a lot and have trouble maintaining attention to the task. Present level: This is French class and this is the second language for most students. Teacher must intervene twice in one minute unless it is a song they are doing.

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PARTICIPANT 3 Level of attainment

Goal 3: quality of N.’s participation Goal 4: transition from one task to another

Much less than expected outcome (-2)

Current performance in January: N. chooses to play with the dolls with simple scenarios which she repeats most of the time.

Current performance in January: Most students can transition from one ‘academic’ task to another of similar nature with 10 + prompts most of the time.

Somewhat less than expected outcome (-1)

N chooses to play with the dolls and engages in creative scenarios that vary most of the time.

Most students can transition from one ‘academic’ task to another of similar nature with 7-9 prompts most of the time.

Expected level (0)

Expected performance: N. chooses to actively engage to play in 3 other areas than the doll center, simple play scenarios most of the time.

Expected performance: Most students can transition from one ‘academic’ task to another of similar nature with 4-6 prompts most of the time.

Somewhat more than expected level (+1)

N chooses to actively engage to play in 3 other areas than the doll center and engages in creative scenarios that vary most of the time.

Most students can transition from one ‘academic’ task to another of similar nature with 1-3 prompts most of the time.

Much more than expected level (+2)

Beyond expectations: N. chooses to actively engage to play in 4-5 other areas than the dolls.

Beyond expectations: All students can transition from one ‘academic’ task to another of similar nature with 1-3 prompts most of the time.

Goal 3: Concern: Each student is at different levels. But N in particular has difficulty participating in kindergarten activities due to decreased engagement and attention. Present level: N has repeated kindergarten; her play skills are limited. She always chooses the doll corner and repeats the same play scenario. Play skills are limited. Goal 4: Concern: Transitions from one ‘academic’ task to another of similar nature is difficult. Present level: It takes at least 10 prompts for students to transition from one ‘academic task’ task to another of similar nature. Students don’t listen and teacher must repeat several times.

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PARTICIPANT 4 Goal 1: J.’s engagement to the task Goal 2: teacher’s abilities to deal with cooperation of grade 6 boys and grade 4 boys’ energy level

Much less than expected outcome (-2)

Current performance in January: J engages in the language arts game table of the Daily Five for 1-3 minutes without physical and verbal prompts most of the time.

Current performance in January: Teacher rates himself 7/10 for his abilities in supporting the self-regulation of the boys in class.

Somewhat less than expected outcome (-1)

J engages in the language arts game table of the Daily Five for 4-6 minutes without physical and verbal prompts most of the time.

Teacher rates himself 7.5/10 for his abilities in supporting the self-regulation of the boys in class.

Expected level (0) Expected performance: J engages in the language arts game table of the Daily Five for 7-9 minutes without physical and verbal prompts most of the time.

Expected performance: Teacher rates himself 8/10 for his abilities in supporting the self-regulation of the boys in class.

Somewhat more than expected level (+1)

J engages in the language arts game table of the Daily Five for 10-12 minutes without physical and verbal prompts most of the time.

Teacher rates himself 8.5/10 for his abilities in supporting the self-regulation of the boys in class.

Much more than expected level (+2)

Beyond expectations: J engages in the language arts game table of the Daily Five for 13 + minutes without physical and verbal prompts most of the time.

Beyond expectations: Teacher rates himself 9/10 for his abilities in supporting the self-regulation of the boys in class.

Goal 1: Concern: J’s ability to actively engage in an academic task during the two hours he is at school. Present level: Presently J requires over 25 prompts (prompts every two minutes) during one hour of Daily Five’s when he’s at school for two hours. He engages in a task for two minutes before requiring a prompt. Goal 2: Concern: Cooperation of grade six boys with following teacher’s instructions and high energy level of grade four boys prevents them from engaging in academic tasks. Present level: Teacher rates himself a 7/10 for abilities to supporting the self-regulation of the boys in class.

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PARTICIPANT 4 Level of attainment

Goal 3: V.’s social impulsivity/rudeness

Much less than expected outcome (-2)

Current performance in January: V goes through 0 afternoons with positive interaction with peers without prompts from teacher.

Somewhat less than expected outcome (-1)

V goes through 1-2 afternoons with positive interaction with peers without prompts from teacher.

Expected level (0)

Expected performance: V goes through 3-4 afternoons with positive interaction with peers without prompts from teacher.

Somewhat more than expected level (+1)

V goes through 5-6 afternoons with positive interaction with peers without prompts from teacher.

Much more than expected level (+2)

Beyond expectations: V goes through 6-7 afternoons with positive interaction with peers without prompts from teacher.

Goal 3: Concern: Rudeness/social impulsivity of V with her peers. Present level: Teacher must reprimand her every day for her inappropriate verbal social interactions with peers due to impulsivity.

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PARTICIPANT 5 Goal 1: X.’s endurance to task Goal 2: T. staying on task Much less than expected outcome (-2)

Current performance in January: X. completes 1 reading comprehension section within one month.

Current performance in January: T. attains and maintains attention to task during one hour of individual work time with 13-17 physical or verbal cues from teacher in a one hour period.

Somewhat less than expected outcome (-1)

X. completes 1 reading comprehension section within two weeks.

T. attains and maintains attention to task during one hour of individual work time with 8-12 physical or verbal cues from teacher in a one hour period.

Expected level (0) Expected performance: X. completes 1 reading comprehension section within one week.

Expected performance: T. attains and maintains attention to task during one hour of individual work time with 3-7 physical or verbal cues from teacher in a one hour period.

Somewhat more than expected level (+1)

X. completes 1 and 1/2 reading comprehension section within one week.

T. attains and maintains attention to task during one hour of individual work time with 3-7 physical or verbal cues from teacher during one and a half periods.

Much more than expected level (+2)

Beyond expectations: X. completes 2 reading comprehension sections within one week.

Beyond expectations: T. attains and maintains attention to task during one hour of individual work time with 3-7 physical or verbal cues from teacher during two periods.

Goal 1: Concern: X’s endurance to task. Present level: Due to behaviour and academic difficulties, X works 20 minutes and gets rewarded 10 minutes free time. This is his daily schedule. However, recently, he does not produce much work.

Goal 2: Concern: T has difficulty staying on task. Present level: During one hour of individual work time, teacher requests about 16 times that T must return to task. He gets up, talks to others, plays with objects… he is not on task when required.

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PARTICIPANT 5 Level of attainment

Goal 3: L.’s time to complete tasks

Goal 4: transitions

Much less than expected outcome (-2)

Current performance in January: L. completes work 40-49% of the time within the given time frame.

Current performance in January: Most students take ~10-12 minutes to transition from one activity/task to another most of the time.

Somewhat less than expected outcome (-1)

L. completes work 50-59% of the time within the given time frame.

Most students take 7-9 minutes to transition from one activity/task to another most of the time.

Expected level (0)

Expected performance: L. completes work 60-69% of the time within the given time frame.

Expected performance: Most students take 3-6 minutes to transition from one activity/task to another most of the time.

Somewhat more than expected level (+1)

L. completes work 70-79% of the time within the given time frame.

Most students take 0-2 minutes to transition from one activity/task to another most of the time.

Much more than expected level (+2)

Beyond expectations: L. completes work 80-89% of the time within the given time frame.

Beyond expectations: All students take 0-2 minutes to transition from one activity/task to another most of the time.

Goal 3: Concern: L’s time to complete tasks. Present level: L completes very short tasks during the day but it still takes her longer than others. If the task has a lot of writing or reading, the assignment will not be completed that period. It takes her an extra long time to complete tasks, even dressing to go outside. Goal 4: Concern: Transitions are taking a lot of time. Present level: It takes 10-12 minutes to get settled to begin a new task.

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PARTICIPANT 6 Goal 1: transitions Goal 2: calling out in math Much less than expected outcome (-2)

Current performance in January: The transition from physical education to calm seat work takes ~13-16 minutes.

Current performance in January: During math class, with 4 + prompts most students can wait their turn to give the answer most of the time; several prompts are needed during the individual work time to stay on task.

Somewhat less than expected outcome (-1)

The transition from physical education to calm seat work takes 9-12 minutes.

During math class, with 2-3 prompts most students can wait their turn to give the answer most of the time; several prompts are needed during the individual work time to stay on task.

Expected level (0) Expected performance: The transition from physical education to calm seat work takes 5-8 minutes.

Expected performance: During math class, with 0-1 prompts most students can wait their turn to give the answer most of the time; several prompts are needed during the individual work time to stay on task.

Somewhat more than expected level (+1)

The transition from physical education to calm seat work takes 1-4 minutes.

During math class, most students can wait their turn to give the answer, 0 prompts required; several prompts are needed during the individual work time to stay on task.

Much more than expected level (+2)

Beyond expectations: The transition from physical education to calm seat work takes less than 1 minute.

Beyond expectations: During math class, students can wait their turn to give the answer, 0 prompts required; minimal prompts are needed during the individual work time to stay on task.

Goal 1: Concern: Transition back to class after physical education is difficult. Present level: They come in ‘flying high’ and it takes 15 minutes to get them calm and settled for following instructions in class.

Goal 2: Concern: During math, a few students are quite impulsive and consistently call out the answers without waiting their turn. During math work, they get chatty and need prompts to return to task. Present level: During math, students call out loudly and do not wait their turn and while they are doing their work, they become chatty and need prompts to return to task.

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PARTICIPANT 6 Level of attainment

Goal 3: constant seeking of approval

Much less than expected outcome (-2)

Current performance in January: M. seeks approval from the teacher 4 + times during the period.

Somewhat less than expected outcome (-1)

M. seeks approval from the teacher 3-4 times during the period.

Expected level (0)

Expected performance: M. seeks approval from the teacher 1-2 times during the period.

Somewhat more than expected level (+1)

M. seeks approval from the teacher 0 times during the period.

Much more than expected level (+2)

Beyond expectations: M. seeks approval from the teacher 0 times during the period and any other times he sees her in school.

Goal 3: Concern: M is emotionally immature and has a difficult time socially. Present level: M’s self-esteem is low, has no friends, and tattle tales constantly. In one period, he seeks approval from the teacher at least 4 times in one period.

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PARTICIPANT 7 Goal 1: “catty” girls disrupt class Goal 2: interaction with ASD student Much less than expected outcome (-2)

Current performance in January: It requires 5+ nonverbal prompts to get girls ready or back on task during the double block period most of the time.

Current performance in January: There is 1 interaction between N and teacher during class with prompts from the aide most of the time.

Somewhat less than expected outcome (-1)

It requires 3-4 nonverbal prompts to get girls ready or back on task during the double block period most of the time.

There are 2 interactions between N and teacher during class with prompts from the aide most of the time.

Expected level (0) Expected performance: It requires 2-3 nonverbal prompts to get girls ready or back on task during the double block period most of the time.

Expected performance: There are 2 interactions between N and teacher during class without prompts from the aide most of the time.

Somewhat more than expected level (+1)

It requires 0-1 nonverbal prompts to get girls ready or back on task during the double block period most of the time.

There are 3 interactions between N and teacher during class with prompts from the aide most of the time.

Much more than expected level (+2)

Beyond expectations: It requires 0-1 nonverbal prompts to get girls ready or back on task during the double block period and have them attend to their task for most of the period.

Beyond expectations: There are 3 interactions between N and teacher during class without prompts from the aide most of the time.

Goal 1: Concern: There are ‘catty’ girls who like to solve problems on their own and this is causing problems with the dynamics of the girls. It interferes with class time because they are bringing the problems back to class and they are not emotionally self-regulated to attend and learn. Present level: They come into class talking and trying to solve some issue and teacher must prompt them verbally 6-7 times in a double block period. Goal 2: Concern: N. is a student with ASD who attends English class with his aide one hour a day. Teacher feels uncomfortable and unsure of how much to engage him in classroom activities. Present level: N. engages little in class. He will answer the teacher’s question or read as requested. If he needs to go to the bathroom, he will ask his aide. He has very minimal involvement with the teacher.

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PARTICIPANT 7 Level of attainment

Goal 3: maintaining attention of students Goal 4: transitions

Much less than expected outcome (-2)

Current performance in January: During the period, most students stay on task with 8 + prompts from the teacher most of the time.

Current performance in January: The transition from lunch and recess to the settling down calmly to attend to the task in class takes ~12-15 minutes with a few verbal or physical prompts most of the time.

Somewhat less than expected outcome (-1)

During the period, most students stay on task with 4-7 prompts from the teacher most of the time.

The transition from lunch and recess to the settling down calmly to attend to the task in class takes 8-11 minutes with a few verbal or physical prompt most of the time.

Expected level (0)

Expected performance: During the period, most students stay on task with 0-3 prompts from the teacher most of the time.

Expected performance: The transition from lunch and recess to the settling down calmly to attend to the task in class takes 4-7 minutes with a few verbal or physical prompts most of the time.

Somewhat more than expected level (+1)

During the one and a half period, most students stay on task with 0-3 prompts from the teacher most of the time.

The transition from lunch and recess to the settling down calmly to attend to the task in class takes 0-3 minutes with a few verbal or physical prompt most of the time.

Much more than expected level (+2)

Beyond expectations: During the double block period, most students stay on task with 0-3 prompts from the teacher most of the time.

Beyond expectations: The transition from lunch and recess to the settling down calmly to attend to the task in class takes 0-3 minutes without extra prompts most of the time.

Goal 3: Concern: Teacher is constantly repeating the same thing over and over and is feeling frustrated at having to threaten the students with the use of incident reports. Present level: Teacher is repeating the same things over and over again at least 10 times per period in order for students to stay on task. Teacher is using incident reports as strategy to deal with disruptive behaviours but would like to have more tools. Goal 4: Concern: When students return to class, they are “wired”. Present level: It takes about 15 minutes and several prompts to settle down for the task.

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PARTICIPANT 8 Goal 1: D.’s cooperation Goal 2: E.’s focus Much less than expected outcome (-2)

Current performance in January:: During transitions, D. goes from one task to another with 3-4 prompts 56-70% of the time.

Current performance in January:: E. waits and takes turns calmly and patiently in oral discussions with 3 + verbal or visual prompt most of the time.

Somewhat less than expected outcome (-1)

During transitions, D goes from one task to another with 3-4 prompts 71-85% of the time.

E. waits and takes turns calmly and patiently in oral discussions with 2 verbal or visual prompt most of the time.

Expected level (0) Expected performance: During transitions, D. goes from one task to another with 1-2 prompts 71-85% of the time.

Expected performance: E. waits and takes turns calmly and patiently in oral discussions with 1 verbal or visual prompt most of the time.

Somewhat more than expected level (+1)

During transitions, D goes from one task to another with 1-2 prompts 86-100% of the time.

E. waits and takes turns calmly and patiently in oral discussions with 0 verbal or visual prompt most of the time.

Much more than expected level (+2)

Beyond expectations: During transitions, D. goes from one task to another with 0 prompts 86-100% of the time.

Beyond expectations: E. waits and takes turns calmly and patiently in oral discussions with 0 verbal or visual prompt and she maintains attention after her turn has passed prompt most of the time.

Goal 1: Concern: Student D is unable to cooperate. Present level: During transitions, she is unable to go from A to B or to change task without the support of several verbal prompts.

Goal 2: Concern: Student E does not engage with others. Present level: During oral presentations, E talks out of turn, gets upset if she needs to wait her turn, and doesn’t stay engaged once her turn has passed. She requires several prompts to maintain appropriate waiting behaviour.

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PARTICIPANT 8 Level of attainment

Goal 3: E.’s nose picking Goal 4: transitions with D.

Much less than expected outcome (-2)

Current performance in January: E. keeps her finger out of her nose during the morning with several prompts required most of the week.

Current performance in January:: D. comes into the school after recess without fussing or prompts required less than 49% of the time.

Somewhat less than expected outcome (-1)

E. keeps her finger out of her nose during the morning with 3-4 prompts most of the week.

D. comes into the school after recess without fussing or prompts required 50-69% of the time.

Expected level (0)

Expected performance: E. keeps her finger out of her nose during the morning with 1-2 prompts most of the week.

Expected performance: D. comes into the school after recess without fussing or prompts required 70-89% of the time.

Somewhat more than expected level (+1)

E. keeps her finger out of her nose during the morning and at special activities with 1-2 prompts most of the week.

D. comes into the school after recess without fussing or prompts required 90-100% of the time.

Much more than expected level (+2)

Beyond expectations: E. keeps her finger out of her nose during the morning and at special activities with 0 prompts most of the week.

Beyond expectations: D. comes into the school after recess without fussing or prompts required 90-100% of the time and gets to class with her peers without prompting.

Goal 3: Concern: E picks her nose constantly thus creating a hygiene issue in class since she doesn’t always wash her hands. Present level: E picks her nose with her left index finger while working, during story time, and throughout the day.

Goal 4: Concern: D refuses to come back into the school after recess. Present level: D requires adult intervention to come into the school after recess. She hides or stays behind the group and does not want to come in.

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PARTICIPANT 9 Goal 1: chatty students during mini-transitions

Goal 2: transitions

Much less than expected outcome (-2)

Current performance in January: Most students remain quiet 0-30% of the time during mini-transitions with three prompts.

Current performance in January: Most students transition back to calm and ready to receive instructions within 5 + minutes of the end of break with 3-4 prompts most of the time.

Somewhat less than expected outcome (-1)

Most students remain quiet 31-60% of the time during mini-transitions with one prompt.

Most students transition back to calm and ready to receive instructions within 3-4 minutes of the end of break with 3-4 prompts most of the time.

Expected level (0) Expected performance: Most students remain quiet 61-90% of the time during mini-transitions with one prompt.

Expected performance: Most students transition back to calm and ready to receive instructions within 1-2 minutes of the end of break with 3-4 prompts most of the time.

Somewhat more than expected level (+1)

Most students remain quiet 91%-100% of the time during mini-transitions with one prompt.

Most students transition back to calm and ready to receive instructions within 1-2 minutes of the end of break with 1-2 prompts most of the time.

Much more than expected level (+2)

Beyond expectations: Most students remain quiet 91%-100% of the time during mini-transitions with no prompts.

Beyond expectations: Most students transition back to calm and ready to receive instructions within 1-2 minutes of the end of break with no extra prompts most of the time.

Goal 1: Concern: Students are chatty during mini transitions: Present level: If there is a pause or an interruption, such as when asked to take out books, while changing from one subject to another, if teacher must answer the door or answer another student’s question (they feel that if teacher is talking to one student during a lesson that she is teaching, they are allowed to talk as well) they will lose focus on the task and begin chatting. Teacher is constantly repeating and requesting them to stay quiet. This occurs every time during a mini-transition and it takes at least 3 requests from the teacher asking them to be quiet.

Goal 2: Concern: Transitions are difficult. Present level: Students are arriving from a variety of different places. Not easy to get settled, now they are doing silent reading and this helped. Transition after the break (between periods) takes 5 minutes and several prompts.

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PARTICIPANT 9 Level of attainment

Goal 3: Ac.’s endurance to task Goal 4: T.’s endurance to task

Much less than expected outcome (-2)

Current performance in January: Ac. stays on task for most of the period with 5+ prompts most of the time.

Current performance in January: T. stays on task for most of the period with 5 + prompts most of the time.

Somewhat less than expected outcome (-1)

Ac. stays on task for most of the period with 3-4 prompts most of the time.

T. stays on task for most of the period with 3-4 prompts most of the time.

Expected level (0)

Expected performance: Ac. stays on task for most of the period with 1-2 prompts most of the time.

Expected performance: T. stays on task for most of the period with 1-2 prompts most of the time.

Somewhat more than expected level (+1)

Ac. stays on task for the whole period with 1-2 prompts most of the time.

T. stays on task for the whole period with 1-2 prompts most of the time.

Much more than expected level (+2)

Beyond expectations: Ac. stays on task for the whole period with 0 extra prompts most of the time.

Beyond expectations: T. stays on task for the whole period with 0 extra prompts most of the time.

Goal 3: Concern: Ac’s endurance to task is short. Present level: He frequently gets up to go to the bathroom. He cannot stay attentive to individual work for very long. Teacher must prompt him 5-6 times in one period for him to stay on task.

Goal 4: Concern: T’s endurance to task is short. Present level: T prefers to play computer games. He often seeks a space to hide out in class. When angry, he leaves the room. He won’t ask for help. Staying on task is difficult. He requires 5-6 prompts during the period to stay on task during individual work time.

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PARTICIPANT 10 Goal 1: attention to task Goal 2: Ic.’s initiation to the task Much less than expected outcome (-2)

Current performance in January: Regardless of the seat they are using or where they are working in the class, 76-80% of the students can attend independently to their task for 5 minutes without teacher prompting most of the time.

Current performance in January: Ic initiates the assigned work task with 4+ prompt from teacher most of the time.

Somewhat less than expected outcome (-1)

Regardless of the seat they are using or where they are working in the class, 81-85% of the students can attend independently to their task for 5 minutes without teacher prompting most of the time.

Ic can initiate the assigned work task with 2-3 prompts from teacher most of the time.

Expected level (0) Expected performance: Regardless of the seat they are using or where they are working in the class, 86-91 % of the students can attend independently to their task for 5 minutes without teacher prompting most of the time.

Expected performance: Ic initiates the assigned work task with 0-1 prompt from teacher most of the time.

Somewhat more than expected level (+1)

Regardless of the seat they are using or where they are working in the class, 92-96% of the students can attend independently to their task for 5 minutes without teacher prompting most of the time.

Ic can initiate the assigned work task with 0-1 visual prompt from teacher and maintain attention to task for 2 minutes most of the time.

Much more than expected level (+2)

Beyond expectations: Regardless of the seat they are using or where they are working in the class, 92-96% of the students can attend independently to their task for 8 minutes without teacher prompting most of the time.

Beyond expectations: Ic can initiate the assigned work task with 0-1 visual prompt from teacher and maintain attention to task for 4 minutes most of the time.

Goal 1: Concern: Use of chair ball is not as effective as before. Present level: A few students use the ball chair but it does not appear to be making a difference to their attention to task. Some should use it but don’t. There are a variety of places students can work but despite this, 26% of students have a hard time focusing their attention to the task. Goal 2: Concern: Ic loves his teacher. He cannot get enough of her. If he could, he could sit on her. He has difficulty with self-regulation, self-esteem and independence; in class,

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he can be explosive. Ic relies heavily on the teacher for prompting him. Present level: Ic requires constant prompts from his teacher. He is unable to get to work without at least 5 prompts from her. And once he starts, maintaining the attention to task is very difficult. PARTICIPANT 10 Level of attainment

Goal 3: A.’s self-regulation Goal 4: engaging students during writing tasks

Much less than expected outcome (-2)

Current performance: A. is calm and alert in order to initiate an academic task with 4-6 prompts most of the time.

Current performance in January: Teacher rates her performance to engage and maintain students’ attention during writing tasks a 7/10 or less.

Somewhat less than expected outcome (-1)

A. is calm and alert in order to initiate an academic task with 1-3 prompts most of the time.

Teacher rates her performance to engage and maintain students’ attention during writing tasks a 7.5/10.

Expected level (0)

Expected performance: A. is calm and alert in order to initiate an academic task with 0 prompts most of the time.

Expected performance: Teacher rates her performance to engage and maintain students’ attention during writing tasks an 8/10.

Somewhat more than expected level (+1)

A. is calm and alert in order to initiate an academic task with 0 prompts and maintains attention to the task for 2 minutes most of the time.

Teacher rates her performance to engage and maintain students’ attention during writing tasks an 8.5/10.

Much more than expected level (+2)

Beyond expectations: A. is calm and alert in order to initiate an academic task with 0 prompts and maintains attention to the task for 4 minutes most of the time.

Beyond expectations: Teacher rates her performance to engage and maintain students’ attention during writing tasks a 9/10.

Goal 3: Concern: A.’s difficulty initiating a task due to poor self-regulation. Present level: His is unable to initiate an academic task without prompts. He requires at least 6 prompts in 30 minutes. Goal 4: Concern: Difficult to get students ready and engaged for handwriting tasks. Present level: Students find handwriting difficult and transition to handwriting tasks is difficult; there are avoidance behaviours such as stating they don’t understand, need to sharpen pencil, change seats, and are missing tools to write. Teacher feels that her ability to deal with this is 6/10.

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PARTICIPANT 11 Goal 1: getting students’ attention Goal 2: maintaining student attention Much less than expected outcome (-2)

Current performance in January: In the morning, 70% of students take ~9 + minutes to settle and be ready to attend to the teacher most of the time.

Current performance in January: Teacher teaches for ~8 minutes before giving several visual or verbal prompts for students to return their attention to lesson most of the time.

Somewhat less than expected outcome (-1)

In the morning, 70% of students take 3-8.59 minutes to settle and be ready to attend to the teacher most of the time.

Teacher teaches for 7-14 minutes before giving several visual or verbal prompts for students to return their attention to lesson most of the time.

Expected level (0) Expected performance: In the morning, 70% of students take 2-2.59 minutes to settle and be ready to attend to the teacher most of the time.

Expected performance: Teacher teaches for 15-22 minutes before giving several visual or verbal prompts for students to return their attention to lesson most of the time.

Somewhat more than expected level (+1)

In the morning, 80% of students take 2-2.59 minutes to settle and be ready to attend to the teacher most of the time.

Teacher teaches for 15-22 minutes before giving 2-3 visual or verbal prompts for students to return their attention to lesson most of the time.

Much more than expected level (+2)

Beyond expectations: In the morning, 90% of students take 2-2.59 minutes to settle and be ready to attend to the teacher most of the time.

Beyond expectations: Teacher teaches for 15-22 minutes before giving 0-1 visual or verbal prompts for students to return their attention to lesson most of the time.

Goal 1: Concern: Getting students attention due to their poor self-regulation. Present level: Students require at least 10 minutes to settle and get ready to attend to teacher. Teacher must repeat several times to be quiet before he can begin his lesson. They continue talking, moving around and being inattentive.

Goal 2: Concern: Maintaining students’ attention is difficult. Present level: Students are chatty when teacher is talking. Frequently tries to regain their attention during one lesson; he can teach for 8 minutes before prompting.

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PARTICIPANT 11 Level of attainment

Goal 3: : S.’s attention to task Goal 4: J. attending to instructions

Much less than expected outcome (-2)

Current performance in January: S. engages in the academic task for the whole period with 4 + physical or verbal prompts most of the time.

Current performance in January: J. attends to teacher when he is speaking to class so she can recall 38-53% of the instructions most of the time.

Somewhat less than expected outcome (-1)

S. engages in the academic task for the whole period with 2-3 physical or verbal prompts most of the time.

J. attends to teacher when he is speaking to class so she can recall 54-69% of the instructions most of the time.

Expected level (0)

Expected performance: S. engages in the academic task for the whole period with 0-1 physical or verbal prompts most of the time.

Expected performance: J. attends to teacher when he is speaking to class so she can recall 70-85% of the instructions most of the time.

Somewhat more than expected level (+1)

S. engages in the academic task for the whole period at the same time as his peers most of the time.

J. attends to teacher when he is speaking to class so she can recall 86-100% of the instructions most of the time.

Much more than expected level (+2)

Beyond expectations: S. engages in the academic task for the whole period at the same time as his peers and will ask peers to stop bothering him if they do most of the time.

Beyond expectations: J. attends to teacher when he is speaking to class so she can recall 86-100% of the instructions and begin them on her own most of the time.

Goal 3: Concern: S. has difficulty staying engaged in the task. Present level: Teacher must prompt him 3-5 times during one period due to difficulty maintaining his engagement to the task.

Goal 4: Concern: J. has difficulty with self-regulation. Engagement is an issue. Present level: J. is unable to understand instructions if given in group situation. Social situations are difficult; conflicts arise often. When teacher is speaking to group, J. is disengaged. She is unable to begin the task without getting individual instructions.