Self-regulation Strategies of Children with Emotional Disturbance

Transcription

1 Self-regulation Strategies of Children with Emotional Disturbance Karin J. Barnes, PhD, OTR Kimberly A. Vogel, EdD, OTR Alison J. Beck, PhD, OTR Heidi B. Schoenfeld, MA, OTR Steven V. Owen ABSTRACT. Children with emotional disturbance frequently have difficulty regulating their classroom behaviors. Many have co-occurrence of other disabilities, such as sensory problems, which compound difficulties in school participation. This exploratory project evaluated the 8-week-long use of the Alert Program within the classroom setting for seven children with emotional disturbance. Five children with emotional disturbance served as a control group. Self-regulation, behavioral adjustments, and sensory skills as reported by the children and Karin J. Barnes, PhD, OTR, is Associate Professor, Occupational Therapy, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Kimberly A. Vogel, EdD, OTR, is Associate Professor, Occupational Therapy, University of Texas Health Science Center at San Antonio. Alison J. Beck, PhD, OTR, is Associate Professor, Occupational Therapy, University of Texas Health Science Center at San Antonio. Heidi B. Schoenfeld, MA, OTR, is Coordinator for Occupational, Physical and Music Therapy, San Antonio Northside Independent School District, San Antonio, Texas. Steven V. Owen, is Professor, Epidemiology & Biostatistics, University of Texas Health Science Center at San Antonio. Address correspondence to: Karin J. Barnes, Associate Professor, Occupational Therapy, Mail Code 6245, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas ( barnesk@ uthscsa.edu). Physical & Occupational Therapy in Pediatrics, Vol. 28(4), 2008 Available online at C 2008 by Informa Healthcare USA, Inc. All rights reserved. doi: /

2 370 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS teachers were evaluated. Changes from pretest to posttest indicated that children who received the Alert Program demonstrated a small improvement on all measures while performance of the control group remained relatively constant or decreased. These preliminary results indicate programs that target self-regulation skills may be useful in helping to improve self-regulation of children with emotional disturbance. KEYWORDS. Children, emotional disturbance, self-regulation, school tasks, occupational therapy The Surgeon General s report stated, One in ten children and adolescents suffers from mental illness severe enough to cause some level of impairment (U.S. Public Health Service, 2000, p. 9). According to the Twenty-fourth Annual Report to Congress emotional disturbance is the fourth largest disability group in the public school system, and nearly a half million such children were provided special education and related services in the public schools in (U.S. Department of Education, 2001). Children with emotional disturbance often have difficulty performing school occupations involving following directions, completing deskwork, and regulating behaviors at school (Prior, 2001). They may have problems in organizational, interpersonal, self-control, coping, and learning skills. Emotional disturbance often co-occurs with learning disorders and sensory problems (U.S. Department of Education, 2000). Studies have demonstrated that children with emotional disturbance frequently show deficits in sensory environmental information (Dunn, 2001; Olson, 2001; Prior, 2001). Children with learning disorders and sensory problems exhibit difficulties with frustration control, self-regulation, self-control, and academic tasks (Miller, Reisman, McIntosh, & Simon, 2001). Children with emotional disturbance have been underserved by school occupational therapists (Beck, Barnes, Vogel, & Grice, 2006). Large caseloads, emphasis on handwriting, and other staff s lack of awareness of occupational therapists training in mental health contribute to the exclusion of children with emotional disturbance from occupational therapy services. Some therapists do not feel competent to address the needs of such children (Barnes, Beck, Vogel, Grice, & Murphy, 2003). Additionally, few studies are available indicating that occupational therapy intervention results in improved educational outcomes for children with emotional disturbance.

3 Barnes et al. 371 The Alert Program (Williams & Shellenberger, 1996) is a systematic intervention designed to help children who have difficulty staying on task or who become upset due to sound, touch, vision, and movement. The program aims to help children (a) learn to recognize their arousal states within the environment as related to behavioral problems, such as their sensitivity and reactions to sounds, touch, and movement in their surroundings and (b) expand their self-regulation strategies used in various school occupations. The Alert Program uses cognitive learning and sensory activities to help children become aware of, maintain, or change their levels of alertness to match the demands of a situation or task (Williams & Shellenberger, 1996). In a school setting, self-regulation of alertness translates to readiness to learn and participation in school occupations. For example, if a child has difficulty staying on task, the child could use an oral strategy, such as chewing on a straw, to help stay focused. As another example, if the entire class was having difficulty quieting down following a transition, the teacher could have all the children push on the wall as a means to provide proprioceptive input to help regulate their arousal levels (Williams & Shellenberger, 1996). Grove (2002) suggested that the Alert Program could be adapted to help children understand their emotional states and maintain self-control in different situations. She credited the Alert Program as an easily implemented approach to address children s psychosocial needs. Salls and Bucey (2003) used the Alert Program in a middle school special education, collaborative classroom-based curriculum to help the children self-regulate their behavior and improve communication skills. Children showed progress in self-awareness, problem solving, and self-regulation strategies, although results were not analyzed statistically. Additionally, teachers, principals, speech therapists, and occupational therapists found it to be cost-effective and a model for best practice in a school setting (Salls & Bucey, 2003, p. 15). Schoonover (2002) used the Alert Program with kindergartners, first and second graders to teach social skills. All children had problems with social awareness, peer relationships, self-regulation, and expressive language, which interfered in their student and friend occupations. Although results were not analyzed statistically, after a year of intervention, group leaders concurred that all the children showed improvements in social skills. Although the Alert Program was reported as one of the most frequently used interventions by occupational therapists providing services to children with emotional disturbance, research evidence is lacking (Barnes et al., 2003). Barnes, Schoenfeld, Garza, Johnson, and Tobias (2005) conducted a small preliminary study using the Alert Program with three boys, ages years old, with emotional disturbance and sensory problems

4 372 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS using a multiple baseline time series design. The program was provided in a self-contained classroom for children with emotional disturbance in a public school. Data were analyzed using trend line analysis; no inferential statistical analysis was used. Results were inconclusive but children showed trends in improvement of social behaviors and self-concept, and a decrease in classroom negative behaviors. The purpose of the present study was to evaluate the Alert Program (Williams & Shellenberger, 1996) for children with emotional disturbance in classroom settings. The following research question was addressed: to what extent does use of the Alert Program result in improvement in (1) sensory, (2) self-regulation, and (3) behavioral adjustment skills of children with emotional disturbance as reported by the children and teachers? Design METHOD This study used a quasi-experimental pretest/posttest design with a control group, and was conducted in the classrooms of the participants. This design was selected due to the limitation of small numbers in each classroom. The study examined the effectiveness of the Alert Program on the behaviors of the children in two classrooms, compared to the corresponding behaviors of children in two control classrooms who received the standard educational programs. Because this study was conducted in the students natural environment using existing classes for children with emotional disturbance, randomized group assignment nor alteration of the classroom makeup was not possible. Participants The 12 participants were children, ages 9 to 11 years old, in four classrooms for children with emotional disturbance in a public school. Because this study was conducted in the children s classrooms, child characteristics were not specified a priori. Each classroom had three to four children. All children had the special education classification of emotional disturbance as determined by the school psychologist based on criteria as specified in IDEA (IDEA, 2004). For eligibility purposes, IDEA 04 defines emotional disturbance (ED) as it relates to learning, the educational environment, and

5 Barnes et al. 373 behavior not conducive to learning (Chander, 2007). Each child took between 1 5 medications for his or her emotional disturbance. Intelligence Quotient (IQ) was measured by the school psychologist, using a variety of valid standardized measurement tools. Eleven children had IQ scores between 77 and 123 and one child had a score of 57 (mild mental retardation). In the intervention group, there were 5 boys and 2 girls; 5 were white, 1 black, and 1 Hispanic. In the control group, there were 5 boys: 3 white, 1 black, and 1 Hispanic. The study was approved by the Institutional Review Board of The University of Texas Health Science Center at San Antonio and the public school district s external research board. Informed consent of parents and assent of children were obtained. Measures Sensory Profile In this study, teachers completed the Sensory Profile on each child. The Sensory Profile (Dunn, 1999) is a standardized measure of sensory abilities of children, ages 5 10 years old designed to profile effects of sensory on functional performance of daily living tasks. The Sensory Profile consists of 125 items and three main sections: Sensory Processing, Modulation, and Behavioral, and Emotional Responses. Scores are interpreted as follows: a Typical Performance score is one that is at or above 1 Standard Deviation (SD) below the mean; a Probable Difference score is one that is at or above the 2 SD but below 1 SD from the mean; and a Definite Difference score is below 2 SD from the mean (Dunn, 1999). Devereux Behavior Rating Scale (DBRS) (BRS)-School Form The Devereux Behavior Rating Scale (DBRS) (BRS)-School Form (Naglieri, LeBuffe & Pfeiffer, 1993) is a standardized measure of interpersonal problems, inappropriate behaviors/feelings, depression, and physical symptoms/fears for children (5 18 years). The DBRS evaluates behaviors that are typical of children with moderate to severe emotional disturbance. Behavior ratings are interpreted as standard scores with significance levels reported. In this study, the children s teachers completed the Devereux.

6 374 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS Measures of Self-Efficacy for Self-Regulation Self-efficacy for self-regulation was measured by two tools: child self-report and teacher report. The Self-Efficacy for Self-Regulation of School-aged Children and Teacher s Perception of Student s Efficacy in Self-Regulation instruments were developed for this study. The selfregulation items concern the children s abilities to regulate their behaviors within the environment. The aim is for the child and teacher to look at how effective the child is at self-regulation. The format of the instruments uses self-efficacy questions such as How good are you at calming yourself down after something bothers you? The support for this format comes from Bandura s (1989) research on self-efficacy. Bandura (1989) emphasized the importance of self-efficacy beliefs...asdeterminantsofhuman motivation, affect, and action (p. 1175) and proposed self-efficacy as a useful way to measure behavioral change. Owen and Froman (2007) indicated, Research in a variety of fields has repeatedly shown the importance of self-efficacy in influencing motivation, self-regulated behavior, affect, and accomplishment (p. 3). Self efficacy refers to a belief that one can accomplish some behavior (Owen & Froman, 2007, p. 1) and is frequently measured by statements of how well the person believes he or she is able to do something (Schwarzer, 1998). Before these instruments were used in this study, 12 occupational therapists, who work with children with emotional disturbance, rated each of the items for relevance and importance. For content validity evidence, intraclass correlation coefficients (ICC) were calculated to examine the experts congruence about the perceived relevance and importance of various items. The ICC for relevance was.75 and the ICC for importance was.80. The magnitude of the coefficients suggested that the experts had general agreement about the relevance and importance of the items. Additionally, item usability was assessed by asking four children (not in the study) if they understood each question, and, if not, how to say it better. The children made suggestions about word changes. For example, one boy suggested that the word sluggish be changed to sleepy. Their suggestions were incorporated into the final wording to improve clarity. Inter-rater agreement was evaluated by scoring seven children not included in the study. Percent agreement across three scorers was A checklist, Self-Efficacy for Self-Regulation of School-aged Children, was designed to ask the child to describe his or her perception of how well he or she is able to regulate behaviors in the classroom, playground, during work tasks and during transition from task to task. This instrument consists of 31 behaviors organized under the categories: (1) monitoring

7 Barnes et al. 375 self, (2) organizing self, (3) maintaining a task, (4) completing a task, (5) adjusting to changing conditions, (6) coping with sensory environmental challenges, (7) having control after being upset, (8) getting help from adults, and (9) getting along with others. A scale of 1 to 5 is used (1 = very poor, 5 = very good). Mean scores are used to interpret each behavior. The children answered the questions for this checklist. A checklist, Teacher s Perception of Student s Efficacy in Self- Regulation, was developed in which the teacher reports a child s ability to self-regulate, using the same 31 items, and the same 5-point response scale as in the child s self-report version. Procedures The first four authors implemented the study. Two authors provided the intervention and two authors administered the pretest and posttest measures. The authors who were in the control classroom were those that conducted the testing. Prior to the start of the study, the teachers of children in the intervention group attended a training session given by the researchers. They were provided an overview of sensory and its importance in everyday life, along with training in the Alert Program. Pretest measures were administered within 2 weeks prior to the start of the intervention phase. The intervention phase lasted 8 weeks. The two classrooms attended by children in the intervention group received the Alert Program intervention from one researcher each. The number of weekly sessions started with three for weeks 1 3 and decreased by one session every 2 weeks. The two researchers conducting the intervention followed the steps and procedures as described in the Alert Program manual, with the children for the duration of the study, with the assistance of the teacher and classroom assistant. The teachers incorporated the Alert Program strategies into the ongoing classroom activities. During the 8 weeks the Alert program was provided, a researcher attended each of the two classrooms of children in the control group during class times and assisted the teacher with the routine classroom activities. Therefore, there was a researcher in each of the control group classrooms for the same amount of time as in the intervention group classrooms. The two researchers providing the intervention met regularly throughout the 8 weeks to ensure that they were using the same procedures as specified in the Alert Program manual thereby standardizing the intervention. The same sequence and general activities as specified in the manual were used in the classrooms. Some variation was allowed for individual children,

8 376 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS such as participation in book fairs and fieldtrips, but this did not alter the sequence or type of intervention. At the end of the 8 weeks, the posttest measures were administered. Data Analysis In this exploratory study, the very small sample creates poor statistical power, making it difficult to detect treatment effects. Although p values were reported, descriptive summaries and effect sizes were emphasized, which are independent of sample size (Vaughan, 2007). The pretest posttest results from the Sensory Profile were analyzed using comparison of the mean group pretest scores to the mean group posttest scores. The participants standard scores on the Devereux Behavior Rating Scale were analyzed to determine if there were significant differences between the pretest and the posttest standard scores, using the significance level of p =.10 (90%). The probability level was determined by comparing the range of scores of the posttest that could have occurred due to measurement error and regression effects. When a posttest score was outside of this range, then it may be concluded that the posttest score represented a significant change in behavior (Naglieri et al., 1993). Significance of change was obtained by using the Posttest Confidence Ranges for Pretest Posttest Standard Score Comparisons table in the DBRS manual (Naglieri et al.). The participants scores on the two checklists, Self-Efficacy for Self- Regulation of School-aged Children and the Teacher s Perception of Student s Efficacy in Self-Regulation, were analyzed to determine if there were differences between the pretest and the posttest scores. The central statistical procedure was a 2 (group) 2(occasion) repeated measures ANOVA. Such an ANOVA model produces three significance tests, but the main effects are typically ignored in favor of the interaction term. The interaction question asks whether the two groups changed differently over time. Sensory Profile RESULTS Pretest results of the Sensory Profile indicated that all 12 children had some sensory difficulties in the Sensory Processing, Modulation, and or Behavior & Emotional Responses Sections.

9 Barnes et al. 377 TABLE 1. Sensory Profile Section Summary: Intervention Group Teachers Responses Mean Scores [ = mean score] Intervention group [n = 7] Pretest Means Posttest Means Factors Typical Probable Definite Typical Probable Definite Performance Difference Difference Performance Difference Difference Sensory A. Auditory B. Visual C. Vestibular D. Touch E. Multisensory F. Oral sensory Modulation G. Sensory relatedtoendurance/tone H. Modulation related to body position & movement I. Modulation of movement affecting activity level J. Modulation of sensory input affecting emotional responses K. Modulation of visual input affecting emotional responses & activity level (Continued on next page)

10 378 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS TABLE 1. Sensory Profile Section Summary: Intervention Group Teachers Responses Mean Scores [ = mean score](continued) Intervention group [n = 7] Pretest Means Posttest Means Factors Behavior & Emotional Responses L. Emotional/Social responses M. Behavioral outcomes of sensory N. Items indicating thresholds for response Summary mean score totals Typical Probable Definite Typical Probable Definite Performance Difference Difference Performance Difference Difference Intervention Group The mean Sensory Profile scores for the seven children in the intervention group indicated little change between pretest and posttest scores (Table 1). Mean scores that improved from Probable Difference to Typical Performance were for the specific factors of Auditory Processing, Behavioral Outcomes of Sensory Processing and the Items Indicating Thresholds for Response. In the specific factor of Multisensory Processing, the posttest score changed from Typical Performance to Probable Difference. Control Group The mean Sensory Profile scores for the five children in the control group indicated a decrease between pretest and posttest from Typical Performance to Probable Difference for the factors of Multisensory Processing, Oral

11 Barnes et al. 379 TABLE 2. Sensory Profile: Control Group Teachers Responses Mean Scores [ = total means] Control group [n = 5] Pretest Means Posttest Means Factors Typical Probable Definite Typical Probable Definite Performance Difference Difference Performance Difference Difference Sensory A. Auditory B. Visual C. Vestibular D. Touch E. Multisensory F. Oral sensory Modulation G. Sensory relatedtoendurance/tone H. Modulation related to body position & movement I. Modulation of movement affecting activity level J. Modulation of sensory input affecting emotional responses K. Modulation of visual input affecting emotional responses & activity level ( Continued on next page)

12 380 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS TABLE 2. Sensory Profile: Control Group Teachers Responses Mean Scores [ = total means](continued) Behavior & emotional responses L. Emotional/ social responses M. Behavioral outcomes of sensory N. Items indicating thresholds for response Summary mean score totals Sensory Processing, Sensory Processing Related to Endurance/Tone, and Modulation of Sensory Input Affecting Emotional Responses (Table 2). Devereux Behavior Rating Scale (DBRS) The results for the DBRS indicated that both groups pretest scores were similarly spread from normal to very significant problems. Six children in the intervention group demonstrated improvement in the posttest standard score and one child showed a decrease (Table 3). Of those showing an improvement, two were significant changes (p =.10) and for the subject with a decreased standard score, the change was significant (p =.10). All of the children in the control group showed decreases on posttest standard score and of these, four were significant decreases (p =.10). Self-Efficacy for Self-regulation and Teacher Perceptions of Student s Efficacy in Self-regulation Table 4 includes the percent change of each child on each measure. There were differences between child self-appraisal and teacher appraisal. In 9 out of 12 children, the child self-ratings were higher than those of

13 Barnes et al. 381 TABLE 3. Change from Pretest to Posttest Scores on Devereux Behavior Rating Scale Subjects Standard score change Intervention group 1 improved 2 improved 3 improved 4 improved 9 improved 10 improved 11 decreased Control group 5 decreased 6 decreased 7 decreased 8 decreased 13 decreased p =.10 their teacher. The discrepancies between child and teacher ratings were very wide for the children in the control group, at both pretest and posttest. Table 5 summarizes the ANOVA for child self-reported self-regulation of self-efficacy. No effect was statistically significant, although the Group main effect showed an effect (η 2 =.18) medium in size, according to Cohen s (1988) guidelines. The interpretation of the Group effect is that the children in the control group average pre/post scores were higher than those of the children in the intervention group. Control group average pre/post scores were higher than those of the children in the intervention group. Note, however, that calculating the average of pre and post scores says nothing about change over time, and the Group effect may simply be an artifact of non-random group membership. That is, by chance alone, students in the control condition began with substantially higher self-efficacy scores, which gave them an advantage in the overall Group effect (see Table 5). Table 6 summarizes the ANOVA for teacher ratings of child efficacy in self-regulation. The Group effect was significant (p =.04), with a large effect size. Examination of the group means shows that the teachers rated the children in the control group substantially lower at both pretest and posttest. Neither within-groups effect Occasion or Group Occasion were significant, but the interaction term nonetheless showed a large effect (η 2 =.25). Inspection of the cell means shows that teacher ratings improved

14 382 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS TABLE 4. Pretest to Posttest Percent Change for Self-Efficacy for Self-Regulation of School-Aged Children and Teachers Perception of Student s Efficacy in Self-Regulation Subjects Children s perceptions Teachers perceptions Intervention Group Individuals Percent Change 1 3% 12% 2 +46% +32% 3 +10% +21% 4 +44% +21% 9 13% +22% 10 7% +7% 11 3% 16% Control Group Individuals Percent Change 5 1% 9% 6 +8% 7% 7 +2% 4% 8 4% 8% 13 1% 29% over time for the children in the intervention group (pre = 3.2; post = 3.5), but declined for the children in the control group (2.5 to 2.2).* Sensory Profile DISCUSSION All of the children presented with some sensory abilities outside of the Typical Performance range. Teachers reported an improvement toward Typical Performance in posttest scores for the children in the in- TABLE 5. Analysis of Variance Source Table for Child-Reported Self-Regulation Self-Efficacy Source SS df MS F p Eta squared Group Error between Occasion <.01 1 < <.01 Group Occasion. <.01 1 <.01 < <.01 Error within

15 Barnes et al. 383 TABLE 6. Analysis of Variance Source Table for Teacher-Reported Self-Regulation Self-Efficacy Source SS df MS F p Eta squared Group Error between Occasion Group Occasion Error within tervention group, whereas the posttest scores of the children in the control group remained the same or moved away from the Typical Performance compared to their pretest scores. This implies that the Alert Program may have helped the children in the intervention group in their adaptation to the classroom sensory environmental contexts. The reason why the control group scores decreased is unknown. The results of this study suggest the Alert Program may have contributed to improved sensory skills in the classroom, as measured by the Sensory Profile, in children with emotional disturbance. The small sample size and the length of the study, however, are causes for caution in regards to possible changes in sensory. Devereux Behavior Rating Scale-School Form (DBRS) While children in the intervention and control groups had similar ranges of pretest scores from normal to very significant problems on the DBRS, the intervention group s posttest scores showed improvement in behavioral skills. This suggests that the Alert Program experience may have helped the children in the intervention group improve in the behavioral areas tested by the DBRS, specifically in their interpersonal skills, appropriate behavior and feelings, depression, and physical symptoms/fears, as observed by the teachers. We surmise that the classroom-based Alert Program intervention has helped the children learn and use strategies of self-regulation of those behaviors targeted by the DBRS. Self-Efficacy for Self-Regulation of School-Aged Children Within group scores (Table 4) of the intervention group varied widely after children participated in the Alert Program. This may indicate that

16 384 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS some children became more effective at self-monitoring and self-regulating their behavior, thus rating themselves higher in the posttest. For example, a child in the intervention group stated, Liked activities. Sit on red thing. Have to ask my teacher to use them. Learned to use them when you get excited or hyper. Others may have gained realization that they need to self-regulate, but felt they were not effective in doing so, and so rated themselves lower. With additional time and practice, perhaps the children would improve their ability to self-regulate and perceive success, leading them to report higher scores on the self-rating form. The control group scores showed little change and little variation. Teacher s Perception of Student s Efficacy in Self-regulation Results for the Teacher s Perception of Student s Efficacy in Selfregulation indicate that teachers perceived that children in the intervention group showed an improvement in self-regulation ability while children in the control group s ability to self-regulate behavior decreased. Results suggested the Alert Program was effective in helping to improving children s abilities to self-regulate, change tasks, organize themselves, cope with sensory challenges, and focus on tasks in the classroom as perceived by teachers. However, it must be noted that the teachers of the children in the intervention group received initial training and participated in the Alert Program interventions, which may have caused bias. The findings suggest that children with emotional disturbance may be unaware of their difficulties with self-regulation or how their behavior is perceived by others. Nine out of twelve children rated themselves considerably higher than teachers rated them on pretest and posttest measures. A curious finding was the contrast between Child 9 s posttest self rating, which was much lower than her pretest rating, and the teacher s posttest rating, which was much higher than Child 9 s posttest rating. The teacher stated that Child 9 had developed more effective self-regulation, in contrast to Child 9 s apparent feelings about her own abilities. While this study was limited in size and by small changes across the pretest and posttest measures, the results suggest that self-regulation and sensory interventions, such as the Alert Program, that target classroom occupations can be viable classroom interventions used by occupational therapists and teachers. Because the Alert Program was conducted in the classroom the teachers were able to learn as the children learned. With this in-class interaction, the teachers exhibited

17 Barnes et al. 385 enthusiastic cooperation and willingness to carry out the program. Together the occupational therapists and the teachers could customize the activities to the individual classrooms. The Alert Program strategies were used throughout the day, thus increasing the amount of practice and generalization for the children. The fact that the intervention occurred in the classroom and involved the teachers helped them to become more perceptive of children s sensory problems and to the classroom sensory environments. The teachers told the occupational therapists that between intervention sessions they recognized the need for the children to use Alert Program strategies and encouraged them to do so. This increased awareness may have helped the teachers anticipate environmental sensory triggers so consequential negative reactions could be avoided. A classroom intervention could allow teachers to use group influence to help individual children when they have behavioral difficulties related to the sensory environment. For example, if a child is having difficulty regulating her behavior during a group assignment, a teacher can stop and request that the entire class engages in a 60-s self-regulatory activity. This allows them to all work together and model for each other ways to obtain the appropriate arousal level for the assignment. Thus, an individual child is neither singled out nor stigmatized. Attention to each child s self-regulation behaviors is especially important in classrooms for child with emotional disturbance because one child s negative behavioral escalation can have a contagion effect on other children s behaviors. This study has limitations that restrict generalization. A small sample from one school in a specific geographic location was used. The classroom environments were more highly structured than regular education classrooms, so generalization to other types of classrooms is limited. Also, the apparent co-occurrence of emotional disturbance with sensory problems with these children does not imply that co-occurrence with other disorders is an automatic finding for children with emotional disturbance. The researchers did not control for the family environment, which, especially in this population, may affect the children s performance. The children had differing medication profiles for their emotional disorders, which can influence performance skills and client factors. The researchers were unable to monitor the medication regimen and dosage. Lastly, while there were improvements in the intervention group scores over that of the control group, the changes were small and represent preliminary data. More clinical research and increased classroom use is needed to confirm the value of the Alert Program in strengthening classroom self-regulations skills.

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19 Barnes et al. 387 U.S. Department of Education. (2000). Twenty-second Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act. Washington, DC. U.S. Department of Education. (2001). Twenty-fourth Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act. Washington, DC. U.S. Public Health Service. (2000).Report of the Surgeon General s Conference on Children s Mental Health: A National Action Agenda. Washington, DC: Department of Health and Human Services. Retrieved June 17, 2005, from Vaughan, R. D. (2007). The importance of meaning. American Journal of Public Health, 97, Williams, M. & Shellenberger, S. (1996). How does your engine run? A leader s guide to the Alert Program for Self-regulation. Albuquerque, NM: Therapy Works.

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