The Alert Program

1
The Alert Program for Self Regulation an
evaluation of a group based intervention for
children attending a child and adolescent mental
health service (CAMHS)
Cremin K1., Lamb K2., OConnell V3. 1Discipline
of Occupational Therapy, Trinity College Dublin,
2.Lucena Clinic, Rathgar 3.Mater Child and
Adolescent Mental Health Service.

• The Program
• The Intervention programs were run by two
  occupational therapists and two students.
• There were two groups, a children's group (6-9
  year olds) and a pre teen group (10- 12 year
  olds).
• Each group was made up of
• Five weekly 1 ½ hr Sessions with the children.
• Two evening,1½ hr Parent/Teacher information
  sessions. Parents were invited and encouraged to
  bring staff from schools.
• One 1 ½ hr Follow up session / review with
  feedback to parents.
• The Alert Program uses the analogy of how does
  your engine run? to facilitate children in
  learning about their levels of alertness and
  arousal using the metaphor of engine speeds. For
  example if your engine is running in high gear
  you may feel angry, overactive or giddy. The
  program has three stages 1) identifying engine
  speed, 2) experimenting with methods to change
  engine speeds and 3) regulating engine speeds.
  Each stage has a series of steps designed to help
  the students with self-regulation. The program
  is run to incorporate these stages and steps but
  can be applied in a variety of ways. (William and
  Shellenberger 1996)

Introduction In CAMHS children who have a primary
diagnosis of ADHD, high functioning autism and
Aspergers syndrome frequently have comorbidity
with self and sensory regulation disorders(Dunn
Bennet, 2002 and Dunn et al. 2002) Treatment
options can include medication, parenting groups
and occupational therapy. One of the programs
frequently offered by occupational therapists is
the Alert Program. This program is a cognitive
and experiential approach based on sensory
integration principles designed to be used with
children with self and sensory regulation
difficulties. The application of the program to
groups of children with emotional disturbance,
particularly in the classroom setting has been
shown to be useful. (Barnes et al.
2003,Colangelo, 2008 Maas, Mason Candler, 2008
and Salls Bucey, 2003). However, these reports
do not have any research evidence for its merits.
The difficulties in researching the effectiveness
of the program most likely lie in its flexibility
of implementation and the fact that many of the
children participating in the program will also
be involved in other therapies.

Parent Feedback and Teacher Feedback Feedback was
gathered through post group survey . Thematic
analysis as outlined in figure 2 demonstrates
mainly positive impressions. Parents and teachers
both reported that they found the strategies and
language of the program helpful, but asked for
more information sessions specific to their
individual child's presentation.
Figure 2 thematic analysis of the parent and
teacher feedback
Conclusion

• While the treatment group made no significant
  gains on measures of attention, behaviour and
  social skills (at home and school) when compared
  to the control group, overall there was parent
  and teacher satisfaction with the treatment
  group. Several factors may have contributed to
  these results, two of the most likely being the
  short length of the intervention and the lack of
  sensitivity of the measures.
• The treatment group showed a significant
  difference in goal attainment when compared to
  the control group. i.e. the treatment group
  achieved participation based goals which the
  control group did not. (goals independently set
  with researcher not clinic OTs). This appears to
  be related to the specific and personal nature of
  the goals.These findings confirm findings of
  Mailloux et al. 2007 that GAS offers therapists
  a unique method of capturing outcomes that are
  truly meaningful to children and familiesp.258
• Limitations of the study include
• That the researchers / participants were not
  blind to allocation and treatment.
• That it was not possible to control for external
  variables other than medication and parenting
  group e.g. change of school or teacher, diagnosis
  and engagement levels.
• Recommendations include
• Further research with larger samples.
• Further investigation of child suitability for
  alert program who decides and how?
• Investigation of factors which influence
  outcomes, i.e. length of program, engagement of
  child, parent and school, clinic environment.
• Assessment of best practice in terms of size,
  format and location of the group.

• Aims
• This research project aimed to examine if a group
  of children participating in a 6 week Alert
  Program
• Made any gains in sensory processing, attention,
  behaviour and social skills (at home and school)
  as measured by standardised measures.
• 2) Achieved individualised goals set around self
  regulation and related behaviours as measured by
  Goal Attainment Scaling (GAS)

Results .
The mean change scores for standardised measures
of  sensory processing, attention, behaviour and
social skills showed no statistically significant
differences between  the control and intervention
group (pgt.05), the mean scores on GAS were
significantly higher for the intervention group
than the control group as Table 2 outlines.
Figure 1 shows the spread of the GAS scores for
the intervention group compared to the control
group.
Methods An experimental pre-post test design was
utilised. Inclusion criteria for the study were
that the child was not on medication, parents
were not attending parenting group at time of
program, the child was between 6 and 12 years and
assessed by CAMHS team as requiring intervention
for self regulation. 26 children who were
referred for the program and consented to
participate were randomly allocated to
intervention or control (no intervention) group.
(22 children participated fully , one was
prescribed medication and removed from the study
and three were lost to follow up in the control
group). Table 1 shows the time frame for the
study.
Test P-value
Short Sensory Profile .378 (ns)
SPM - home .701 (ns)
SPM - school .244 (ns)
Leiter cognitive - home .577 (ns)
Leiter emotional home .832 (ns)
Leiter cognitive - home .496 (ns)
Leiter emotional - home .937 (ns)
CBCL total .165 (ns)
TRF total .336 (ns)
GAS .021 (s)
children Week 1 Week 2-8 Week 9-13 Week 14
13 (12 male 1 female) Pre-test Alert program Assimilation Post-test
9 (8 male 1 female) Pre-test No intervention No intervention Post-test
Table 2 p-values for mean change scores between
pre and post measures
References
Table 1 time frame for study

• Pre and post test measures were used (based on
  previous research by Miller et al 2007)
• Short Sensory Profile
• Sensory Processing Measure (SPM), home and
  classroom version
• Leiter International Performance ScaleRevised
  Parent Rating Scale and Teacher Rating Scale
  (LeiterR)
• The Child Behavior Checklist (CBCL) 
• Goal Attainment Scaling (GAS)

Barnes, K.J., Beck, A.J., Vogel, K.A., Grice,
K.O., Murphy, D. (2003). Perceptions regarding
school-based occupational therapy for children
with emotional disturbances.American Journal of
Occupational Therapy, 57, 337-341. Colangelo, C.
(2008). Test Drive Introducing the Alert
Program through song (Reviews,Tidbits and
Tools). Journal of Occupational Therapy, Schools,
Early Intervention, 11,70-71. Dunn, W.,
Bennett, D. (2002). Patterns of sensory
processing in children with attention deficit
hyperactivity disorder. Occupational Therapy
Journal of Research, 22(1), 4-15. Dunn, W.,
Myles, B., Orr, S. (2002). Sensory processing
issues associated with Asperger Syndrome a
preliminary investigation. American Journal of
Occupational Therapy, 56, 97-102. Maas, C.,
Mason, R., Candler, C. (2008, Oct. 20). When I
get mad. An anger management and
self-regulation group. OT Practice,
9-14. Mailloux, Z., May-Benson, T.A., Summers,
C.A., Miller, L.J.,Brett-Green, B., Burke, J.P.
et al. The Issue Is Goal attainment scaling as
a meausure of meaningful outcomes for children
with sensory integration disorder. American
Journal of Occupational Therapy,61,254-259.
Miller, L.J.,Coll, J.R. Schoen, S.A.(2007).A
Randomized controlled pilot study of the
effectiveness of occupational therapy for
children with sensory modulation disorder.
American Journal of Occupational
Therapy,61,228-238. Salls, J. Bucey, J. (2003,
March 10). Self-regulation strategies for middle
schoolstudents. OT Practice, 11-16. Williams,
M.S. Shellenberger, S. (1996)."How does your
engine run?" A leader's guide to the Alert
Program for self-regulation. Albuquerque, NM
TherapyWorks, Inc
Figure 1 box plot of intervention and control
groups GAS scores
2
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