A critical review of research on the ALERT Program®

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Read Full Text: A critical review of research on the ALERT Program® (full article must be purchased)
Journal: Journal of Occupational Therapy, Schools, and Early Intervention
Year Published: 2018
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Article overview for OTs

The ALERT Program® is a 12-week self-regulation system that helps students incorporate sensory integration into the processing of various tasks. The program helps teach children and adults how to monitor, maintain, and change their level of alertness to address the specific needs of a number of tasks and contexts.

The ALERT Program® is one of the most frequently utilized interventions in the OT world, having been implemented in schools, clinics, research studies, and home settings. In fact, the popular OT question “How does your engine run?” comes from the program.

The evidence behind the ALERT Program® has been strong so far; several randomized control trials (RCTs) have reflected favorably on the program. However, until until now, nobody had completed a systematic review of evidence (considered the gold standard in the research world) regarding the program.

This study conducted a systematic review, looking at six published researched studies examining the use of the ALERT program®. The researchers evaluated whether the ALERT Program® met the following criteria for individuals with self-regulation deficits:

  • Was the program effective in meeting its goals?
  • Was the program feasible for use with its intended clients?
  • Was the program an appropriate choice considering other options?

The authors concluded that the evidence for the Alert Program® is strong to promising. Elementary Secondary Education Act (ESEA) guidelines were used, and results indicated that the Alert Program® may be a feasible, universal self-regulation intervention for school settings. The program can likely be successfully sustained by teachers, depending on the target population and setting.

Information on the ALERT Program®

The Alert Program® was created by two occupational therapists. To learn more about the program, please visit their website: https://www.alertprogram.com/.

Assessments utilized when implementing the ALERT Program®

Diagnoses of children in the study included:

  • Children with social disadvantages
  • Children with emotional disturbances
  • Fetal Alcohol Syndrome Disorder (FASD)
  • Children with psychosocial and speech therapy needs
  • Typically developing children

Improvements identified after completing ALERT Program® included:

  • Classroom behavior
  • Self-regulation
  • Teachers’ understanding of self-regulation
  • Emotional control
  • Planning and organization
  • Inhibition
  • Overall executive functioning

Improvements of children with Fetal Alcohol Syndrome Disorder (FASD) included:

  • Response inhibition
  • Outcome monitoring
  • Emotional regulation
  • Teachers’ understanding of challenging behaviors and effective strategies for classroom use of program

The articles were analyzed by the Effective Public Health Practice Project (EPHPP) quality assessment tool. The EPHPP reviews six domains of study methods, including study design and data collection. The articles were also reviewed by the Elementary and Secondary Education Act (ESEA) guidelines which evidenced the use of effectiveness of evidenced-based activities, strategies and interventions for schools.

Limitations

  • Only six studies met the inclusion criteria for the systematic review
  • The studies ranged from weak to moderate strength of evidence, using the Effective Public Health Practice Project (EPHPP) quality assessment tool
  • Modifications to the program, including parent and teacher educational components, occurred in some of the studies—and some articles did not have any fidelity measures reported
  • One study reported that improvement in self-regulation may have been impacted by the positive teacher and parent interactions, not solely the ALERT program®

Additional takeaways for occupational therapy practitioners

  • Completing all three stages and mile markers as described in the manual, including 12 week sessions, is essential to fully harness the ALERT Program®—but some parent and teacher training modifications can improve intervention consistency
  • In order for the ALERT Program® interventions to be effective, caregivers must be involved. They should be apprised of, and taught how to implement, any strategies being used from the program.

Listen to a summary in podcast form

Find other platforms for listening to the OT Potential Podcast here.

What questions/thoughts does this article raise for you?

Thank you to Katie Caspero, MS, OTR/L for helping me find and review this article!

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Thanks very much for sharing this article! I am wondering if anyone has implemented it in private practice? I have been to a 1-day training on it several years ago and use pieces of it. If so could you share some information on that? Also what is the Effective Public Health Practice Project (EPHPP) quality assessment tool?
Thank you, Tee

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I have not used this program in my career of working mostly with older adults as an OT so cannot weigh in on your good questions @tee.

What I do find fascinating is the absolute emphasis on training those on the front lines… the caregivers/teachers/parents. It seems that no matter where in any “system” (whether the school or traditional health care system) it can be so tempting to overlook strong and quality inclusion of these people (and ultimately the relationship) in our training. When I reflect back, I came out of school believe (falsely) that my time working with a caregiver was not skilled. Now I am learning to see it different and research like this (albeit that this research is about a very specific program) helps to prove the point and value of doing so though, and doing it well.

What has helped others in not only including caregivers/teachers/parents in OT, but also doing it effectively and within timely ways? Perhaps especially or also in this very ALERT Program (thought I’d be curious to know in general also).

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Thank you so much for sharing this! I’m just making my way into the world of pediatrics and becoming familiar with the Alert Program. I had some experiences with it about 5 years ago when I did a one week pediatric rotation. During that week, I observed pieces of the Alert Program being very effective for increased self-awareness and self-regulation. In my opinion, I did see such a need for this to be consistent across home, school, and clinic use for increased effectiveness. If there was not carryover in the home and/or the school, the 30-60 minute therapy cuing was not nearly as effective. I am curious to see further research on adapting for various populations as each child is so individual with their individual needs.

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@katie have you used the Alert Program in a private practice setting?

@tee, thanks for weighting in! Here is a link to the EPHPP: https://link.springer.com/content/pdf/bbm%3A978-3-319-17284-2/1

The tool helps you rate a study from weak to strong in the following areas:

  1. selection bias;
  2. study design;
  3. confounders;
  4. blinding;
  5. data collection methods;
  6. withdrawals and dropouts;
  7. intervention integrity;
  8. analysis.
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Hi @Rsaltzgaber! Welcome to the Club! I’m excited for you to be making your way into pediatrics.

I totally agree with you, carryover seems to be part of the reason this program works! We are seeing across all of the research in the Club that repetition in a key part of effectiveness. And, so we need caregivers and family members to help us get in the necessary repetitions.

Also, if anyone is reading this thread and knows about new studies where the Alert Program was adapted for various populations, please let us know! I definitely anticipate this to be a topic of new research and I can’t wait to read it!

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Ha! Yes! I definitely had the same thoughts about caregiver education when I left school.

I also falsely believed that the most important thing for the patient was what was happening in our sessions, when in reality, the most important work is happening outside of our sessions. Our sessions are just priming the client for work in the “real world.” We know that to impact neuroplasticity lots of repetitions need to be happening… and the best way to get in these reps is real world practice!

Thank goodness for caregivers as partners in healing!

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Thank you for the tool Sarah!!

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@tee I have used the Alert Program in an outpatient private practice setting and now I use it in a non-profit outpatient clinic. I usually read through the weekly activity and then adapt it based on working 1:1 with the kids. I usually write goals for social and community participation as the functional outcome for being able to self-regulate themselves using 1-2 tools through the Alert program if that is helpful from a reimbursement standpoint.

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@monika I agree including the caregivers is something OTs look at when looking at the environmental contexts whether that’s adult or children. I have found asking right off the bat what’s the best way they learn (watching a session, having it written down, or hearing it auditory) can help save a lot of repetition of training when it comes to caregiver education. I’ve also had the parents record the session so they can reference it later. Usually a lot of them have smartphones with a camera so this can help with carryover.

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SMART @katie. Genius on the recording with the phone and the asking. Tis both amazing and humbling how the simplest of things work the best (like asking “how do you learn the best?”). Thank you.

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