Christopher J. Alterio, DrOT, OTR
Jennifer Welninski, OTS
Danielle Green, OTS
Lauren Martin, OTS
Christopher J. Alterio, DrOT, OTR is owner of ABC Therapeutics in East Amherst, NY and directed the study. Jennifer Welninski was a student at D’Youville College and assisted in research design and proposal writing. Danielle Green was a student at Quinnipiac College and assisted in data collection. Lauren Martin was a student at D’Youville College and participated in data collection. All students participated in this research project as part of their Level II Fieldwork experience at ABC Therapeutics. The research project was conducted during 2007.
Statement of the Problem
Howda Designz created a seat product for adults and children that is being used by schools and parents nationwide. Anecdotal evidence supports claims regarding the benefits of using the seat. However, higher level clinical evidence is lacking. This company is a small business and they lack sufficient resources to conduct clinical trials. Research into the actual effectiveness of the product is needed.
Statement of the Purpose
The purpose of this pilot study is to determine whether the HowdaHUGs seat increases attending behaviors during circle time for preschool-aged children.
Brief Literature Review
A company named Howda Designz (2007) created a seat product for children. The HowdaHUGs seat is a wooden flexible seat with no legs that contours around the body. According to Howda Designs (2007), the chair provides back support and feels like a “hug” to a child’s body. The product comes in a variety of sizes and an adjustable model is available (Howda Designz, 2007).
According to the Howda Designz website (2007), children are calmer while using the chair. This claim is justified by the linear movement or rocking motion that the chair provides. Furthermore, it provides a ‘hug-like’ feeling for the child. It is believed that this deep pressure makes children feel more peaceful and calm and assist them in focusing and listening while in circle time (Howda Designz, 2007).
Interestingly, this product has been produced and sold for 20 years (Howda Designz, 2007). Fairly recently, the design has been used for children. As stated in the previous section, this product is associated with anecdotal benefits and effects for children, and even for relief of back pain in adults. The company states that they are a small business, and therefore they are unable to study the effects of the chair on outcomes such as attention and calmness. Anecdotal evidence from parents and school personnel seem to support the claims made by the company (Howda Designz, 2007). Several possibilities can be considered as to why the chair seems to increase attention and promote calmness. The first is the concept of deep pressure.
Most deep pressure research has been completed using weighted vests or other devices. The HowdaHUGs chair presumably supplies a similar type of deep pressure.
Deep pressure is discussed as part of sensory integration theory. Sensory integration theory states that the proprioceptive, vestibular, and tactile systems are important for functioning (Honaker & Rossi, 2005). These systems need to be register and process sensory information appropriately. According to Ayres (1979), if there is dysfunction in sensory processing, a behavioral outcome may be observed (as cited in Olson & Moulton, 2004). According to Vandenberg (2001), these behavioral outcomes may include shifting from activity to activity, being distracted by other stimulation in the room that is not relevant to current activity, restlessness or difficulty staying seated, poor quality school work, and frequently talking or touching peers.
Among these sensory systems, proprioception plays an important role in the principles of sensory integration (Honaker & Rossi, 2005). Proprioceptive input is said to influence sensory integration. Proprioception and deep pressure sensory information is carried by the by the dorsal column to the thalamus and the reticular formation. The reticular system plays an important role in arousal, which may explain the effect of deep pressure on arousal level (VandenBerg, 2001).
Furthermore, deep pressure may stimulate and increase in the neurotransmitter Serotonin. Serotonin leads to calming of the central nervous system (VandenBerg, 2001). Proprioceptive, or deep pressure stimulation, may calm other sensitive systems such as the tactile and vestibular, and modulate arousal level (Honaker & Rossi, 2005).
As illustrated, the influence of deep pressure, a type of proprioceptive input, is believed to be beneficial to assist children in calming and organizing multisensory systems. Deep pressure can be provided through numerous activities. These include: weighted vests, weighted toys, backpacks, holding therapy (Edelson, Edelson, Kerr, & Grandin, 1999), and weighted blankets (Fertel-Daly, Bedell, & Hinojosa, 2001). Many therapeutic activities can be used to provide deep pressure input. The HowdaHUGs chair may increase attending behaviors through this mechanism.
Other possibilities exist beyond sensory stimulation as a cause of positive effects of the HowdaHUGs chair on children’s arousal level and attention. The chair may work as a mere function of its design. It contains children by reducing the space available to them, in other words it ‘contains’ them. The area available for movement is decreased; thereby it may facilitate increased attention and decreased motor activity. The exact reasoning behind the proposed effects of the HowdaHUGs chair is unknown.
Significance and Justification
According to Howda Designz (2007), occupational therapists are using the HowdaHUGs chair with children in school-based settings and they are recommending them to parents. It is apparent that these qualified professionals have seen the benefits of the product in their practice setting. While personal experience is undoubtedly important, evidence is lacking for these claims. In a document located on The American Occupational Therapy Association website, Case-Smith (2004) states that continuing competence requires the use of research in practice. Occupational therapists should include literature searching and reading as part of their continuing competence (Case-Smith, 2004). The results should be integrated into daily practice (Case-Smith, 2004).
Evidence is lacking for the use of the HowdaHUGs chair. In order to justify the use of the product to parents and school personnel and to ensure that occupational therapists are practicing evidenced-based practice, the HowdaHUGs chair should be researched.
The following assumption was believed to be true for the purpose of this research study:
Occupational Therapists and other school professionals desire and will benefit from evidence concerning the effects of the HowdaHUGs chair on the attention of children during circle time.
The following hypothesis was generated for this study:
The use of the HowdaHugs chair during circle time for a period of 15 minutes will increase attending behaviors in preschool age children as measured by a checklist.
Definition of Terms
The terms in the hypothesis were operationally defined.
A typical part of the participating school’s preschool classroom routine whereby children sit together on a rug and participate in songs and activities as a group for a period of approximately 15 minutes.
Attending behaviors were defined as maintaining visual attention on the teacher, positioning of body to face the teacher, following teacher directives, and an absence of distracting behaviors including touching others and standing up or lying down when not instructed to do so by the teacher.
Preschool Age Children
Preschool age children were defined as children who were enrolled in the preschool program at the participating school. These children were all 4 years of age.
The following variables have been identified for this research study:
The independent variable for this study is the HowdaHUGs chair. This chair was given to children to use during circle time and a measurement of their attending behaviors was recorded.
The dependent variable for this study was attending behavior. These behaviors were measured through a structured observation period of 15 minutes. The observations were recorded using a checklist.
This research study had a small sample size; therefore the results of the study may not be generalized to other settings and to other children in other settings.
Procedure for the Collection of Data
The research design was an ABAB design. The ABAB design is a single- subject design which includes four phases. The first and third are baseline phases, and the second and fourth are intervention phases (Ottenbacher & York, 1984). The single-subject design was chosen because it is a practical method of addressing clinical questions. The design allows practitioners to assess changes in client status and the need for changes in intervention method. Single subject designs are helpful for monitoring progress of one or a few individuals (Ottenbacher & York, 1984).
During the first phase, participants were observed without the chairs to collect baseline data. The second phase required the provision of the chairs to the students for circle time when data was collected. The third phase required that the chairs be removed from circle time and observation continued. The fourth phase was the reinstating of the chairs. Observations were recorded. Each phase was a two week period. Two observation sessions occurred during each week resulting in 16 observation sessions.
Setting, Population and Sample
The population from which the sample was derived was preschool students attending an elementary school in the Buffalo, New York area. These children were all 4 years of age.
The sample was derived through the use of teacher recommendation. The researcher obtained list of five students in one of the preschool classrooms. The teacher was asked to list the five students who were believed to have difficulty paying attention in circle time. The teacher was provided with examples of inattention including frequent change of position (standing up or lying down when not instructed), decreased visual attention as compared to other children in the group, and position of the body away from the teacher.
Data Collection methods
Data collection was completed through the use of a checklist. The checklist was broken down into 1 minute intervals for a total time period of 15 minutes. Each behavior that is indicative of paying attention was assessed during each 1 minute period. Sixteen periods of recorded observation took place, two per week for eight weeks. The observations were held over an 8 week period as to attempt to minimize particular classroom changes or individual changes on the results. The purpose of the observations was to achieve an accurate assessment of the effects of the chairs.
The researchers attended the classroom during circle time a week before recorded observations were taken in order to help to integrate their presence into circle time and decrease the amount of distraction of a novel individual during observation periods. The observer was trained in the use of the checklist data collection tool, and a test of competency was completed before the onset of the study. Inter-rater reliability was established prior to actual data collection.
Human Rights Protection
This study involved the use of human subjects. The privacy of the participating individuals was respected. Children were assigned a letter A-E. They were referred to as such throughout the study. Furthermore, the safety of the participants was continuously assessed. The participants were exposed to little or no risk by participating in this study. Careful observation was completed to determine if the chair was having any adverse effects on the participants. No concerns were noted.
Informed consent was obtained before the start of the study. A form was sent home with the five identified children that was signed and returned by the parent.
The tool that was used in this study is a non-standardized checklist. The checklist was created through collaboration of the research leader and an occupational therapy student. The tool provides a quick means of assessing attending behaviors of children during circle time.
Treatment of Data
The data was analyzed through graphic representation and descriptive statistics. The percentage of time each child was paying attention during the 15 minute interval was calculated and compared to baseline and withdrawal observation periods. The information was graphically organized for each component of the ABAB design. Furthermore, for each minute assessment period (15 for each total observation time), the number of behaviors exhibited was totaled and an average was calculated and graphed. It was expected that the average number of attending behaviors displayed during each 15 minute session would increase during the intervention phases.
All of the children responded uniquely to the HowdaHUG seat and there was no consistent pattern of response. Data charts and comments are presented below for each of the children:
Child A was a four year old female child identified as a ‘preschooler with a disability’ and received related services including OT, PT, speech therapy, and counseling. Child A made some improvements in visual attention and facing the teacher when the seat was provided and these attending skills were decreased when the seat was withdrawn. The seat had no notable impact on following directions. The number of other distracting behaviors decreased over the course of the study but changes were not noted associated with presence or absence of the seat.
Child B was a four year old female child identified as a ‘preschooler with a disability’ and received related services including OT and speech therapy. This child made improvements in visual attention, facing the teacher, and following directions but changes were not noted associated with presence or absence of the seat. The child had a significant increase in distracting behaviors over the course of the study.
Child C was a four year old male child identified as a ‘preschooler with a disability’ and received related services including OT, PT, speech therapy, and counseling. The initial introduction of the seat caused some slight improvements in facing the teacher and following directions, but attending behaviors significantly decreased when the seat was withdrawn and then improved again when the seat was provided a second time. It is unknown if the withdrawal of the seat in Period 3 caused the decline in attending behaviors or if there was some other unknown confounding variable that impacted the child’s attending skill during that period.
Child D was a four year old male child identified as a ‘preschooler with a disability’ but was not receiving any related services. There was no appreciable improvement in attending behaviors associated with providing the seat for this child.
Child E was a four year old male child identified as a ‘preschooler with a disability’ and received related services including OT, PT, and speech therapy. Child E made notable improvements in visual attention and facing the teacher when the seat was provided and these skills decreased when the seat was withdrawn. A similar pattern of improvement and decline was noted for following directions and absence of distracting behaviors, except that improvement was not seen when the seat was reintroduced in the final period.
Preschool-aged children typically demonstrate a number of common behaviors when they are asked to sit for circle time. Common behaviors observed in the subjects both with and without the chair included playing with fingers, swinging legs to hit another child’s chair, playing with own hair or another student’s hair, standing up, yelling out, turning around to look at other children or data collectors, looking around the room, playing with nearby shelves, getting up to use the restroom, falling out of the chair, looking at their own shirt and pants, pointing at or poking other children, hitting peers, moving chairs, playing with shoes, biting at clothing, and covering head in clothing. While seated in the chair common behaviors included rocking in the chair, wrapping their arms around the chair sides, tilting in the chair sideways, and placing the chair on their head. In short, there are many distracting behaviors that were observed, both in and out of the chair.
Despite attempts to provide some controls many other factors can have an impact on children’s attention. Different circle time leaders used different teaching styles, parents were sometimes present in the classroom, one child was sometimes given theratubing to chew on during circle time, other peers could be disruptive and impact attending, the children sometimes ‘slouched’ in the chair and did not get a full ‘hug’ effect, and the last week of observation was close to a holiday vacation. It may not be possible to control for all of these typically occurring factors in the context of the natural preschool environment and all of these factors can significantly impact attending at any given time.
Despite all of these confounding variables we noticed the most consistent improvement in visual attending and facing the teacher when the children were in the seats:
We noticed significantly less consistency in impact of the seats on following directions and absence of other distracting behaviors:
In this sense, the actual physical design of the seat may have the most significant impact on improving some aspects of attending behavior. The ‘confinement’ factor logically improves visual attention and facing the teacher most. There is less support for the concept of a proprioceptive ‘calming’ factor. There was no consistent evidence noted that the seat promoted being in a better arousal state for following directions or for dampening down other distracting behaviors.
Aside from these observed and recorded observations, the teacher was asked for his qualitative comments at the end of the study. The teacher believed that most of the students attended better when they were in the seats. The teacher noted that attending behaviors improved over the course of the study but that it might not just be from the seats but also from evolving experience with circle time and improved behavioral compliance with teacher expectations over time. The teacher liked that the seats gave the students a confined space to sit in but still allowed for some movement opportunities.
Preschoolers need to develop attending skills so that they can meaningfully participate in typical classroom activities including circle time. Children who are this age have many distracting behaviors that impact their ability to attend. Children who have disabilities may have confounding factors that cause development of attending skills to be impaired.
Preschool-aged children were given the HowdaHUG seat and their ability to attend during circle time was measured. Because the study was completed in the natural environment there were many factors that were unable to be controlled for that influenced the children’s ability to attend. Some of the children demonstrated some improved attending in the seats while other children’s attending skills were unaffected by the seats. For those children who had the most notable improvement, the seats seemed to have greatest impact on visual attending and facing the teacher. This is most likely attributed to the physical design of the seats that provided a measure of physical confinement.
This study provides a model for measuring change in attending behaviors based on use of the HowdaHUG seat. Future studies may attempt stricter controls on the circle time activities and the classroom environment. Future studies may also include a larger number of children and use random assignment to intervention and non-intervention groups.
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