Alert Program®

About This Program

Target Population: Children and adolescents with learning disabilities from fetal alcohol spectrum disorder (FASD) or similar to FASD; and their parents/caregivers [NOTE: The Alert Program® has been used with 0-18 year olds as well as adults, but the CEBC only rated the program based on research studies with children and adolescents the ages below.

For children/adolescents ages: 6 – 13

For parents/caregivers of children ages: 6 – 13

Program Overview

Alert Program® provides an organizing framework and process to address issues of self-regulation for both children and adolescents. The program is designed to take complex sensory processing information related to modulation and self-regulation, and make it accessible for the lay person through:

  • Capitalizing on the higher cognitive functioning by using the cortex for thinking through self-regulation options, to help individuals recognize problems with lower-level functioning
  • Improving sensorimotor regulation which contributes to improved emotional, social, and behavioral regulation, as well as improved executive functioning.
  • Focusing on helping individuals learn to monitor, maintain, and change their level of alertness so that it is appropriate to a situation or task.

Alert Program® consists of activities that incorporate sensory integration techniques with cognitive approaches. Knowledge of self-regulation and a repertoire of sensorimotor strategies enhance one’s ability to learn, interact with others, and work or play within varied environments, in addition to building self-esteem, self-confidence and self-monitoring skills.

Program Goals

The goals of Alert Program® are:

For children and adolescents:

  • Learn how to recognize arousal states as they relate to attention, learning, and behavior.
  • Learn how to recognize and expand the number of self-regulation strategies they use in a variety of tasks and settings.

For parents/caregivers:

  • Help child and/or adolescent recognize and regulate their own arousal states.
  • Understand that child’s and/or adolescent’s behavior may reflect both the current level of organization of the nervous system and the individual’s best attempt to respond adaptively and efficiently to the demands of a situation or task.

Logic Model

The program representative did not provide information about a Logic Model for Alert Program®.

Essential Components

The essential components of the Alert Program® include:

  • Use with individuals (1:1) and/or with small or large groups
  • Uses the analogy of an automobile engine to introduce its concepts of self-regulation. “If our body is like a car engine, sometimes it runs on high, sometimes it runs on low, and sometimes it runs just right.”
  • Process elements critical for success:
    • Inside-out approach to learning
    • Collaborative “detective work”
    • Critical reasoning and creative problem solving
    • Modeling of one’s own levels of alertness and strategies
    • Jargon-free vocabulary
    • Supporting coaching through developmental stages
  • Program is implemented in three stages:
    • Identifying engine speeds/level of alertness
    • Experimenting with methods to change engine speeds/level of alertness.
    • Regulating engine speeds/level of alertness
  • Each stage consists of a series of developmental steps with activities provided to support progression to the next step.
  • Uses sensorimotor strategies from the Mouth, Move, Touch, Look, and Listen categories to support sensory-motor-cognitive developmental interactions and integration.
  • Individuals who are not yet able to become independent in their own self-regulation can be supported with options from trained adults and caregivers.

Program Delivery

Child/Adolescent Services

Alert Program® directly provides services to children/adolescents and addresses the following:

  • Diagnosed with fetal alcohol spectrum disorder (FASD) or has behaviors that fall into that classification such as difficulty coping with changes in routines, difficulty transitioning between activities, inability to focus/attend/listen when required, inability to sustain attention for long periods of time, easily distracted, difficulty handling the unexpected, unable to console self in socially age-appropriate ways, difficulty taking turns, unable to get along with others, difficulty following steps and rules, lack of coping skills for challenging situations, difficulty in playing cooperatively

Parent/Caregiver Services

Alert Program® directly provides services to parents/caregivers and addresses the following:

  • Has a child/adolescent with fetal alcohol spectrum disorder (FASD); has difficulty identifying a child’s behaviors that reflect self-regulation challenges; has difficulty helping the child/adolescent identify potential sensory strategies, has difficulty in helping child/adolescent participate in daily activities; has difficulty supporting child/adolescent client in achieving self-regulation competence through modeling, coaching, and positive feedback

Adult Services

Alert Program® directly provides services to adults (regardless of whether they are parents or caregivers) and addresses the following:

  • NOTE: The Alert Program® has been used with children and adults, but the CEBC only rated the program for children and adolescents. To get this information for adults, please visit their website: alertprogram.com.

Recommended Intensity:

The program can be implemented as a stand-alone program. The intensity of sessions vary depending on the needs of the individual and the environmental context. The program can be fully integrated within the daily routines of an individual’s home, classroom, or system wide.

Recommended Duration:

The amount of time individuals need to learn the different stages varies greatly. Some move through all the steps and states within a few sessions. Others need months to grasp the concepts in just Stage One. Individuals need to learn each step before moving on to the next, but the amount of time spent on each step depends on each individual’s needs and emotional variables.

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Birth Family Home
  • Community Daily Living Setting
  • Foster / Kinship Care
  • Hospital
  • Outpatient Clinic
  • Community-based Agency / Organization / Provider
  • Group or Residential Care
  • School Setting (Including: Day Care, Day Treatment Programs, etc.)

Homework

Alert Program® includes a homework component:

There is homework only as it relates to practicing and assessing discovered strategies within daily routines and environments.

Languages

Alert Program® has materials available in languages other than English:

Dutch, French, Italian, Spanish

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

  • Adequate space for safe movement and sensory-motor activities is required.
  • Sensory-motor activities relevant to the individual’s developmental stage and cultural context is important.

Manuals and Training

Prerequisite/Minimum Provider Qualifications

Anyone can be trained to be a Leader of the program (e.g., parent, teacher, family members, mental health provider, community support personnel, etc.). However, to expertly guide implementation, it is critical that an Occupational Therapist (or other related professional knowledgeable and skilled in the Theory of Sensory Integration and the Alert Program® be on the team in the role as Leader or consultant to the Leader.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Williams, M. S., & Shellenberger, S. (1996). How does your engine run?® A leader’s guide to the Alert Program. TherapyWorks, Inc.

The manual is available for purchase on the website: www.alertprogram.com

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

Training is offered online at www.alertprogramlearning.com.

Number of days/hours:

Online training consists of 20 contact hours for all participants. Self-paced with 2 months access.

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Alert Program® as listed below:

Anyone exploring the Alert Program® is encouraged to peruse the website www.alertprogram.com, which offers many free resources and introductory materials. This will enable one to determine how the program might fit for the identified need. It is important that an organization or individual has a team member or professional consultant who is knowledgeable of the Theory of Sensory Integration and self-regulation. The Leader should complete the Alert Program® Online Course before implementing to learn how to adapt and obtain updated research and best practices.

Formal Support for Implementation

There is formal support available for implementation of Alert Program® as listed below:

Formal consultation and support are available via teleconferencing (for an hourly rate) and email. The Alert Program® provides a consultation service called “Tracking Success” that assists facilities in customizing a program unique to the stated needs. This process provides a framework for implementation, and identifying and measuring program outcomes. Program evaluation strategies are developed to evaluate both the process and the product of implementing the Alert Program®.

Fidelity Measures

There are no fidelity measures for Alert Program®.

Implementation Guides or Manuals

There are implementation guides or manuals for Alert Program® as listed below:

The Leader’s Guide (see manual section above) provides guidance and direction for implementing the program within varied environments. The Leader’s Guide is included in the Alert Program® Online Course providing additional guidance for implementation and adaptation within varied environments and for varied populations.

Implementation Cost

There are no studies of the costs of Alert Program®.

Research on How to Implement the Program

Research has not been conducted on how to implement Alert Program®.

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

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), 369–387. https://doi.org/10.1080/01942630802307127

Type of Study: Pretest-posttest study with a nonequivalent control
Number of Participants: 12

Population:

  • Age — 9–12 years
  • Race/Ethnicity — 8 White, 2 Black, and 2 Hispanic
  • Gender — 10 Males and 2 Females
  • Status — Participants were children in public school classrooms for emotional disturbances.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of this study was to evaluate the use of the Alert Program® within a classroom setting for children with emotional disturbances. Measures utilized include the Sensory Profile, the Devereux Behavior Rating Scale (DBRS), the Self-Efficacy for Self-Regulation of School-aged Children, and the Teacher’s Perception of Student Efficacy in Self-Regulation. Results from pretest-to-posttest indicate that children who receive the Alert Program® demonstrate a small improvement on all measures, while performance of the control group remained relatively constant or decreased. Limitations include lack of randomization of participants, small sample size, reliance on self-report measures, and lack of follow-up.

Length of postintervention follow-up: None.

Bertrand, J. (2009). Interventions for children with fetal alcohol spectrum disorders (FASDs): Overview of findings for five innovative research projects. Research in Developmental Disabilities, 30(5), 986–1006. https://doi.org/10.1016/j.ridd.2009.02.003

Type of Study: Pretest-posttest study with a nonequivalent control
Number of Participants: 78

Population:

  • Age — 6–11 years (Mean=8.73 years)
  • Race/Ethnicity — 42.3% Black and 37.2% White
  • Gender — 67.9% Male
  • Status — Participants were children in public school classrooms for emotional disturbances.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
This summary reports on one of the 5 studies reported in this article. The purpose of said study was to provide a brief overview of the Alert Program® developed for individuals with fetal alcohol spectrum disorders (FASDs), and the methods and general findings of five specific intervention research studies conducted within this framework. The studies evaluated five different interventions in five diverse locations in the United States, with different segments of the FASD population. The specific aim of this study was to develop and evaluate a program of neurocognitive habilitation for children who had been in foster care or who had been adopted, and who had a diagnosis of FASD or alcohol-related neurodevelopmental disorder (ARND). Measures utilized include the Behavior Rating Inventory of Executive Function (BRIEF) and the Roberts Apperception Test for Children (RATC). Results indicate that children who participated in the neurocognitive habilitation program demonstrated significant improvement in executive functioning skills compared with the children in the control group. The children in the treatment group at outcome also differed from those in the control group in their response to a projective storytelling test on the RATC: children in the treatment group told fewer stories that had unrealistic solutions to problems. Limitations include lack of randomization of participants, small sample size, reliance on self-report measures, and lack of follow-up.

Length of postintervention follow-up: None.

Mac Cobb, S., Fitzgerald, B., Lanigan-O’Keefe, C., Irwin, N., & Mellerick, N. (2014). Students with social, emotional, and behavioral difficulties: The Alert Program trial in post-primary schools. Journal of Occupational Therapy, Schools, & Early Intervention, 7(2), 106–119. https://doi.org/10.1080/19411243.2014.930606

Type of Study: Pretest-posttest study
Number of Participants: 84

Population:

  • Age — Children: 12–13 years; Adults: Not specified
  • Race/Ethnicity — Children: 42.3% Black and 37.2% White; Adults: Not specified
  • Gender — Children: 64 Males and 20 Females; Adults: Not specified
  • Status — Participants were students and four teachers.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
This article used the same sample as Mac Cobb, Fitzgerald, & Lanigan-O’Keefe (2014). The purpose of this study was to report on the collaboration between teachers and occupational therapists in the Alert Program® for students with challenging behaviors. The specific aim of this study was to develop and evaluate a program of neurocognitive habilitation for children who had been in foster care or who had been adopted, and who had a diagnosis of fetal alcohol system or alcohol-related neurodevelopmental disorder (ARND). Measures utilized include the questionnaire designed by the National Behaviour Support Service (NBSS) research team; students also completed a questionnaire on their views of the program and their interest in applying their learning (if any) to day-to-day school life. Results indicate that teachers, students, and occupational therapists reported that both content and approach engaged students who learned self-management strategies for the classroom. Limitations include lack of randomization of participants; small sample size; study utilized measures with no psychometrics; that outcomes reported on the appropriateness of the intervention and not on the outcomes of the intervention; and lack of follow-up.

Length of postintervention follow-up: None.

Nash, K., Stevens, S., Greenbaum, R., Weiner, J., Koren, G., & Rovet, J. (2015). Improving executive functioning in children with fetal alcohol spectrum disorders. Child Neuropsychology, 21(2), 191–209. https://doi.org/10.1080/09297049.2014.889110

Type of Study: Randomized controlled trial
Number of Participants: 25

Population:

  • Age — Children: 8–12 years (M=10.35 years); Adults: Not specified
  • Race/Ethnicity — Children: Not specified; Adults: Not specified
  • Gender — Children: 14 Males and 11 Females; Adults: Not specified
  • Status — Participants were children with fetal alcohol spectrum disorder (FASD).

Location/Institution: Motherisk Clinic at The Hospital for Sick Children or an accredited FASD diagnostic facility in Ontario

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine if Alert Program for Self-Regulation® [now called Alert Program®] would produce improvements in self-regulation that would generalize to other aspects of executive function (EF), behavior, and social skills in children with fetal alcohol spectrum disorders (FASD). Participants were randomized to the Alert®-treatment (TXT) or waitlist-control (WL) conditions. Measures utilized include the NEPSY History questionnaire, the Peabody Picture Vocabulary Test–fourth edition (PPVT-4), the Wechsler Abbreviated Scale of Intelligence (WASI), the NEPSY-II, the Test of Everyday Attention for Children (TEA-Ch), the Cambridge Neuropsychological Test Automated Battery (CANTAB), the Test of Social Cognition, the Behavior Rating Inventory of Executive Functioning (BRIEF), the Child Behavior Checklist (CBCL), the Externalizing Problems and Total Problem, and the Social Skills Improvement System (SSIS). Results indicate at the 12-week follow-up, the TXT group displayed significant improvements in inhibitory control and social cognition. Parents of children in the TXT group reported improved behavioral and emotional regulation, as well as reduced externalizing behavior problems. These behavioral improvements, along with further improved parent-rated inhibitory control, were maintained at the 6-month follow-up. Limitations include small sample size; few of the child-administered results approached statistical significance; and unable to examine additional important factors related to outcome, such as IQ, gender, and placement status which also contributed to outcome; it possible that some treatment effects may have been washed out if more children in TXT moved into a higher age category than the DTC group over time, it is also possible that the current findings were influenced by the differential group differences at baseline in terms of the number of cases with ADHD and exposures, sample may not generalize to the larger FASD population because children were excluded with an IQ of 70 or below and had no cases with FAS.

Length of postintervention follow-up: 6-month follow-up (treatment group only).

Nash, K., Stevens, S., Clairman, H., & Rovet, J. (2018). Preliminary findings that a targeted intervention leads to altered brain function in children with fetal alcohol spectrum disorder. Brain Science, 8(1), Article 7. https://doi.org/10.3390/brainsci8010007

Type of Study: Randomized controlled trial
Number of Participants: 21

Population:

  • Age — Children: 8–12 years; Adults: Not specified
  • Race/Ethnicity — Children: Not specified; Adults: Not specified
  • Gender — Children: Intervention 50% Male; Control: 54% Male; Adults: Not specified
  • Status — Participants were children with fetal alcohol system disorder (FASD).

Location/Institution: Southern Ontario

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of this study was to determine whether the Alert® Program for Self-Regulation [now called Alert Program®] improves neural functioning in other associated regions in children with fetal alcohol spectrum disorder (FASD). Participants were randomized to the Alert®-treatment (TXT) or waitlist-control (WL) conditions. Participants were assessed with a Go-NoGo functional magnetic resonance imaging (fMRI) paradigm before and after training or the wait-out period. Measures utilized include the Canadian Diagnostic Guidelines system, the Diagnostic Guide for Fetal Alcohol Syndrome and Related Conditions: The 4-Digit Diagnostic Code, and the Wechsler Abbreviated Scale of Intelligence (WASI). Results indicate that groups initially performed equivalently and showed no fMRI differences. At posttest, TXT outperformed WL on NoGo trials, while fMRI in uncorrected results with a small-volume correction showed less activation in prefrontal, temporal, and cingulate regions. Groups also demonstrated different patterns of change over time reflecting reduced signal at posttest in selective prefrontal and parietal regions in TXT; and increased in WL. In light of previous evidence indicating TXT at posttest perform similar to nonexposed children on the Go-NoGo fMRI paradigm, the findings suggest Alert Program® does improve functional integrity in the neural circuitry for behavioral regulation in children with FASD. Limitations include small sample size, did not examine the impact of other prenatal exposures (e.g., nicotine) on results, did not monitor Alert Program® effects outside the lab to see if children who changed most were ones whose parents who applied the therapy at home, and lack of follow-up.

Length of postintervention follow-up: None.

The following studies were not included in rating Alert Program® on the Scientific Rating Scale...

Mac Cobb, S., Fitzgerald, B. & Lanigan-O’Keefe, C. (2014). The Alert Program for self-management of behaviour in second level schools: results of phase 1 of a pilot study. Emotional and Behavioural Difficulties, 19(4), 410–425. https://doi.org/10.1080/13632752.2014.903593

This article reports on Phase 1 of the Alert Program® with a challenging class groups of students as part of the evidence-informed practice of the National Behaviour Support Service. The purpose of the study was to develop and evaluate a program of neurocognitive habilitation for children who had been in foster care or who had been adopted, and who had a diagnosis of fetal alcohol syndrome or alcohol-related neurodevelopmental disorder (ARND). Measures utilized include the questionnaire designed by the NBSS research team. Students also completed a questionnaire on their views of the program and their interest in applying their learning (if any) to day-to-day school life. Results indicate that teachers reported that the content and class management strategies were appropriate. Students gained an understanding of their behavior and identified self-management strategies for use in the class. They recommended that all teachers working with the class group should be familiar with the language and techniques of the program to reinforce learning. Feedback from 85% (72) of students confirmed that the learning tasks were considered by the majority to be enjoyable and relevant. The group of students perceived to be the most challenging gave the most positive scores, and 100% of these indicated their intention to use their new self-management strategies in class. The results led to Phase 2 of the pilot in which teachers took the lead role, with occupational therapist support, in a national pilot in 16 schools in areas of social disadvantage. Limitations include lack of randomization of participants; small sample size; study utilized measures with no psychometrics; that outcomes reported on the appropriateness of the intervention and not on the outcomes of the intervention; and lack of follow-up. Note: This article was not used for rating Alert Program® in the Fetal Alcohol Spectrum Disorders (FASDs) Interventions (Child & Adolescent) topic area since only part of the intervention was evaluated in the article.

Additional References

National Behaviour Support Service. (2015). The Alert Program in Irish post-primary schools: A NBSS national study of a teacher facilitated self-regulation programme, http://www.nbss.ie/sites/default/files/publications/alert_report2_cover_2.pdf

TherapyWorks, Inc. (2019). Alert Program® literature and research: Published literature, research, and resources. https://www.alertprogram.com/wp-content/uploads/2019/03/AP-Literature-and-Research-3-26-19.pdf

Williams, M. S., Shellenberger, S., & McEwen, M. (2020). The Alert Program® for self regulation. In Bundy, A. C. & Lane, S. J.(Eds.), Sensory integration: Theory and practice (3rd ed., pp.19–32). F. A. Davis. https://www.worldcat.org/title/sensory-integration-theory-and-practice/oclc/1126345681&referer=library_profile&returnRegistryId=70147

Contact Information

Sherry Shellenberger
Title: OTR/L
Agency/Affiliation: TherapyWorks, Inc.
Website: alertprogram.com
Email:
Phone: (505) 897-3469
Molly McEwen
Title: MHS, OTR/L, FAOTA
Agency/Affiliation: TherapyWorks, Inc
Website: alertprogram.com
Email:
Phone: (505) 897-3469

Date Research Evidence Last Reviewed by CEBC: September 2020

Date Program Content Last Reviewed by Program Staff: February 2021

Date Program Originally Loaded onto CEBC: February 2021