Program Proposal

SIGNIFICANCE
Nationally, 1 in 5 children in the United States experiences mental illness each year,
affecting all ethnic, racial, and socioeconomic groups (Centers for Disease Control and
Prevention, 2020). The most common mental disorders in children are anxiety disorders,
attention deficit hyperactivity disorder, disruptive behavior, and mood disorders (Child Mind
Institute, 2015).
Poor emotional regulation is common across psychiatric diagnoses in children (Masi et
al., 2015; Wyman et al., 2010). According to Sheftall et al. (2016), impulsivity is of particular
concern due to its potential role in suicide for this age group. Suicide is the 10th leading cause of
death in children ages 5 - 11, with rates of 0.17 per 100,000 (Sheftall et al., 2016). Other public
health concerns linked to deficits in emotional regulation include depression, addiction,
antisocial behavior, and school absences, suspensions, and expulsions (Stagman & Cooper,
2010; Wyman et al., 2010). Furthermore, poor self-control in childhood is predictive of higher
crime rates as adults (Moffitt et al., 2011). This clearly shows that emotional regulation is a
public health issue that needs to be addressed.

A Multidisciplinary Approach is Needed

Despite the need for services, only about 20% of children with significant mental illness
receive any kind of treatment (Waxman, 2006). The number of people who require mental
health services outstrips the psychiatric professionals available in this field (Torres, 2019). One
solution to eliminate this gap is to utilize health care professions outside the traditional mental
health industry (Wissow et al., 2016). In addition to meeting the workforce shortage, a
multidisciplinary approach to mental health services can increase the range of interventions and
improve long-term outcomes (Colizzi et al., 2020). Occupational therapy provides an excellent
example of a profession that brings unique value to the mental health field (American
Occupational Therapy Association [AOTA], 2016). Occupational therapists are trained to
evaluate strengths and challenges in performance skills, demands of tasks, and contexts, and to
develop treatment plans that target the underlying factors that limit occupations (Januszewski &
Lukaszewski, 2017). Occupations are defined as “various kinds of life activities in which
individuals, groups, or populations engage, including activities of daily living, instrumental
activities of daily living, rest and sleep, education, work, play, leisure, and social participation”
(AOTA, 2017, p. S19). Occupational therapy focuses on enabling occupational engagement,
and outcomes show improved mental health (AOTA, 2016). Sensory-based interventions are
another unique approach that occupational therapy offers (Harrison et al., 2019). Programs
that teach sensory processing skills have shown a positive impact on emotional
regulation (Barnes et al., 2008; Wells et al., 2012). Even though sensory processing disorders
frequently occur with mental illness (Dunn, 2001), sensory-based treatments are largely lacking
in mental health services (Harrison et al., 2019).

Program Overview
We developed a program that aims to improve emotional regulation skills and
enable healthy participation in childhood roles and occupations. It will take place at a
children’s mental health partial hospitalization program in Salt Lake City, Utah, called Kidstar.
This treatment program serves children ages 5 - 12 and they typically attend Kidstar for 6
weeks. Up to 14 children are enrolled in the program at any given time, and they are divided into
two separate classrooms. The children have severe mental illness and exhibit externalizing
behaviors (i.e., aggression, antisocial behavior). These behaviors are associated with poor
emotional regulation (Dvir et al., 2015; Eisenberg, Valiente, & Eggum, 2010). A survey of
Kidstar staff and parents also identified emotional regulation as a particular need for their
population. Children in the Kidstar program are currently unable to attend their typical school
due to emotional and behavioral challenges, which greatly impact their school and homework
performance. Furthermore, the children’s poor emotional regulation skills limit their participation
in all areas of occupation. The current programming at Kidstar does not include a curriculum
that targets emotional regulation skills, particularly as it relates to childhood occupations.
Therefore, we developed a program to address this need.
We used a modified version of the Zones of Regulation curriculum (Kupyers, 2011) as
the foundation of our program due to its use of both sensory and cognitive strategies to improve
emotional regulation. Zones of Regulation categorizes emotions into four different “zones” and
teaches children to recognize when they have entered each zone by referring to their level of
alertness and mood. It teaches strategies (i.e., sensory tools, cognitive approaches) to help
them regulate in their current zone or move to a more appropriate zone for the situation.
Although limited, there is evidence of the effectiveness of Zones of Regulation. Suarez et al.
(2019) used Zones of Regulation to guide individual treatment with four children in an outpatient
clinic who had poor behavior or emotional regulation. The authors identified an increase in self-
regulation from baseline. Additionally, Zones of Regulation may lead to increased independence
in activities of daily living (ADLs) (Suarez et al., 2019). Other studies have found the Zones of
Regulation curriculum is effective in classroom settings (McQuade, 2017) and in a small group-
based intervention for children with fetal alcohol spectrum disorder (Anderson et al., 2017).
Although these studies settings were different from Kidstar, the curriculum increased self-
regulation in children with similar challenges to the children attending Kidstar. The potential of
Zones of Regulation to increase independence in ADLs impacted by poor emotional regulation
indicates that this curriculum, modified for this setting, is a viable option to meet the needs of the
Kidstar population.

Priorities: Kidstar and Healthy People 2020

Our program addresses Kidstar’s need for a focused emotional regulation curriculum.
Through this program, the clients at this site will have an improved understanding of their
emotions and how to regulate them. The clients will learn how to use sensory tools and apply
cognitive strategies to regulate their emotions when they enter a particular zone at an
inappropriate time. Establishing improved emotional regulation skills will directly help children
work towards the aim of Kidstar to reintegrate into a typical childhood life in which they are not a
danger to themselves or others; they will have skills they can refer to when they are in a zone
that can lead to dangerous behavior. In addition to supporting the priority of Kidstar, our
program addresses the Healthy People 2020 goal of improving mental health through quality
services (U.S. Department of Health and Human Services, 2020).
Theoretical Background
The theoretical frameworks that guided the creation of our program are the frame of
reference (FOR) to enhance social participation (Olson, 2010), the acquisitional FOR (Luebben
& Royeen, 2010), and the model of human occupation (MOHO) (Kielhofner, 2009). The FOR to
enhance social participation (Olson, 2010), focuses on developing age-appropriate emotional
regulation and social interaction skills in various environments. Our program aims to improve
emotional regulation skills in the children at Kidstar, leading to overall improved social
participation. When the children better understand their emotions and self-regulate using
calming or alerting tools, they will improve social interactions at school, home, and in the
community. The acquisitional FOR (Luebben & Royeen, 2010) is centered on rewarding desired
behaviors in order to increase positive behaviors and decrease maladaptive ones. Kidstar
currently has a level system in place that gives additional privileges to children whose positive
behaviors move them to higher levels. When our program is implemented, the Kidstar staff will
be able to use their current level system to reinforce each child’s use of emotional regulation
skills. This will encourage the children to continue developing their understanding of their
emotions so they can better regulate as they participate in activities both at home and
throughout the treatment day. Lastly, MOHO (Kielhofner, 2009) is a client-centered model that
addresses how and why we engage in meaningful daily occupations. It suggests that occupation
is influenced by interaction between an individual’s inner characteristics and the environment
and that motivation can be increased by addressing issues in these areas. Through our
program, the children will enhance their motivation to self-regulate and participate in their
occupations.

INNOVATION
Although Kidstar teaches some emotional regulation skills through their current social
skills training curriculum, the children have a limited understanding of emotions, often using
basic vocabulary such as “happy” or “sad” to describe their emotions. The children do not have
a reliable way of categorizing their emotions to help them identify appropriate times to display
and act on those emotions. Our program offers a novel approach to emotional regulation
that is adapted for the specific needs of an intensive mental health treatment program.
Specifically, the children in Kidstar are admitted and discharged on individual schedules, which
is a common feature of treatment programs. To accommodate this, we structured the delivery of
our program so it applies to newly admitted children who are attending their first session and to
children who have been participating in the program for several weeks. A second innovative
feature of our program in this setting is teaching sensory processing skills. We will do this
by completing a sensory evaluation, training children, and educating parents and staff on the
best use of sensory tools. Our program will ensure effective use of sensory tools that can be
generalized across settings to improve the children’s functioning at home, school, and in the
community.
In each session of our program, the children will participate in activities of interest, which
provides opportunities for them to apply the emotional regulation skills being taught. The current
Kidstar curriculum does not address the occupational needs of the child as they relate to
emotional regulation. This is not uncommon in traditional mental health treatment facilities. In
fact, many interventions that currently exist to address emotional regulation have not indicated
long-term effects; therefore, there is a need for children to generalize and adapt these skills
across occupations and environments to increase the program’s effectiveness (Wyman et al.,
2010). Our program addresses this issue by applying the concepts to daily occupations. It will
incorporate activities that the children are interested in to make the curriculum engaging. Role-
playing activities will target how to apply their emotional regulation skills to challenging
occupations. Moreover, involving the family in the program will assist the children in generalizing
their skills beyond treatment.
The creation of an occupational therapy program that meets the needs of children in
intensive mental health treatment will support the value of occupational therapy in this setting.
This can be used to meet the demand for additional providers in this underserved field.

APPROACH
Needs Assessment Demonstrates Emotional Regulation Concerns
We conducted data collection through an interview with the Kidstar director and surveys
from Kidstar staff and parents. Both the director interview and staff surveys indicated that
children have the most difficulty regulating their emotions during school, free-time, and in the
afternoon. In the parent survey, all parents reported that their child has difficulty controlling
emotions, and 75% reported that their child has difficulty expressing emotions. Parents
identified emotional regulation as leading to the most difficulties in occupations in the following
order: school and homework, household chores, sleep and nighttime routine, community
activities, social participation and play, and self-care. We also explored sensory tools and
knowledge of their use in our needs assessment. Results from the staff survey indicate a lack of
in-depth understanding of sensory processing. Kidstar has demonstrated a willingness to invest
in sensory supplies, but an occupational therapist is needed to train staff on how to make use of
sensory tools throughout the programming day. We designed a program with an emphasis on
emotional regulation to address these needs and improve participation in occupations.

Emotion Safari Program

Our program, titled Emotion Safari, will involve six 1-hour sessions. Each session will
follow a similar structure. The first 20 minutes will involve reviewing the four zones by referring
to classroom posters and activities (e.g., playing zones bingo, watching video clips, role-playing
scenarios, drawing a picture of oneself in each zone, identifying personal triggers, and
identifying zones changing across the day). After reviewing the zones, the children will spend
approximately 5 minutes reviewing tools (e.g., weighted blanket, breathing methods) to calm or
alert them when their emotional zone is not appropriate for the situation. The session will
continue with a 10-minute lesson on cognitive strategies to improve emotional regulation, such
as identifying the size of the problem, understanding how one’s behavior impacts others, and
developing new ways of thinking. Next, a 15-minute activity based on the children’s interests will
give children an opportunity to identify their zones and use a strategy to move to different zones
as needed. Each session will close with a discussion to reflect on and generalize the concepts
covered during the session. Children will also be given time to add strategies or items to their
personal “toolbox” that they will develop throughout the program. The toolbox will provide a
tangible resource they can refer to for ideas to help them self-regulate at Kidstar and outside the
program. To reinforce these concepts outside of sessions, children will be asked to identify their
current emotion(s) and zone(s) during check-in periods throughout the treatment day.
In their research on the effectiveness of Zones of Regulation, Suarez et al. (2019)
suggest that parent involvement adds value to the curriculum. Therefore, in our program, an
occupational therapist will provide parents with direct training and resources to support their
child in self-regulating, including individual recommendations for their child’s sensory needs.
No marketing or recruitment is needed for this program because all children currently
enrolled in Kidstar will participate as part of their mental health treatment services.

Goals and Objectives

Goal 1: The children at Kidstar will improve their emotional regulation skills.
● Objective 1a: Participants will be taught the 4 emotional zones within 1 week of starting
the program.
● Objective 1b: By week 3, participants will verbalize which emotion they are feeling and
the corresponding zone in 2 out of 3 opportunities.
● Objective 1c: By week 4, participants will utilize at least 1 strategy from the toolbox to
move to a different emotional zone in 2 out of 3 opportunities.
Goal 2: Parents will be prepared to support the emotional regulation needs of their child at
Kidstar.
● Objective 2a: Parents will be provided a handout about the program within 1 week of
their child starting the program.
● Objective 2b: By child’s discharge, parents will identify 3 tools that they have
successfully used with their child to help them transition from one zone to another.

Addressing Potential Challenges

Since new children are admitted to and discharged from Kidstar on intermittent
schedules, the program must be structured in a way that the order in which each child begins
the program does not make a difference in the final outcome. To address this, instead of
implementing our program with lessons that directly build on previous lessons, we plan to
review the emotional regulation zones and tools at the beginning of each session to familiarize
any new participants with the material. This will ensure that each child is introduced to the
fundamental concepts and overall objectives of the program each week, despite how many
sessions they have attended. The order that the lessons are given will not impact the overall
learning experience. This session structure will provide opportunities for returning participants to
review the concepts they have learned in previous weeks to solidify learning.

Program Evaluation and Measures

Upon admission to the program and within two days of discharge, each child will
complete three subtests of the Social Emotional Evaluation (Wiig, 2008), including recognizing
facial expressions, identifying common emotions, and identifying emotional reactions. This
assessment will be used to measure goal 1. Parents will complete a pre- and post-survey, which
will be used to measure both goals and objective 2b. Qualitative data will be collected by the
occupational therapist throughout the program to measure outcomes for objectives 1a-c and 2a.
Having participants and parents complete the pre-assessment will allow us to establish a
baseline for our program so that we will be able to track progress as participants go through the
program. The post-test assessments will allow us to see the total amount of progress that has
been made based on our identified objectives, as well as any variability between participant and
parent results. The post-survey that parents will complete will allow them to express any
feedback that could potentially make our program more effective in the future. This will allow us
to make adjustments as needed. Furthermore, it will give us a better understanding of how well
the participants are generalizing skills learned in the program into other environments of their
life that are impacted (e.g., home environment, family interactions).

Personnel and Resources

This program will require an on-site occupational therapist (OTR) for 10 hours per week.
The set wage will be $35 per hour. The necessary resources to run the program include a
Zones of Regulation manual, appropriate sensory tools, and zones toolboxes (folders for 140
anticipated participants over 12 months). A Chromebook is required for the OTR to prepare
sessions and complete documentation. The assessment materials needed are the Sensory
Profile 2 (Dunn, 2014) and the Social Emotional Evaluation (Wiig, 2008). The initial grant will be
used to fund this program for a 12-month period.

Program Sustainability
The program requires adding one staff member (OTR) for 10 hours per week. We are
seeking grant funding to establish and run the program for the first 12 months. After that time,
direct services provided by the OTR would be billed to private insurance, which is the current
funding source of Kidstar. Alternatively, additional grant funding could be sought to provide
continued funding for the program. This program requires very few resources to implement. The
supplies and resources needed are low cost and can be used long-term.
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 Budget Justification

DIRECT COSTS ($20,226)

Personnel ($18,200)

Occupational therapy practitioner (OTR)

Role: Key personnel

The OTR will prepare and run two 1-hour sessions each week (3 hours/week), conduct sensory
evaluations on each child in the program and create individualized sensory recommendations
(3.5 hours/week), source appropriate sensory tools and equipment (0.5 hours/week), and
provide parent education during family treatment sessions (3 hours/week).

Appointment: Staff, Kidstar program, University Neuropsychiatric Institute

Effort on Project: 25% total effort

Total Support Requested: $18,200

Organization base salary (12-months): $72,800

Salary requested (25%): $18,200

Fringe benefits requested: $0

Consultants ($0)

N/A

Equipment ($650)

$650 is budgeted to purchase a Chromebook for OTR use in documentation and session
preparation.

Travel ($0)

No travel costs are budgeted.

Participant Costs ($0)

No participant costs are budgeted.

Marketing Costs ($0)

No marketing costs are budgeted.

Other Costs [Supplies] ($1,376)

$1,376 is budgeted for program materials including the Zones of Regulation manual ($74),
sensory tools (fidget toys, wiggle cushions, weighted lap pads: $400), Zones toolboxes (folders
at $1.50 each for 140 children over the year: $1.50x140 = $210), the Sensory Profile 2 manual
and administration materials ($420), and the Social Emotional Evaluation manual and
administration materials ($272). Other necessary materials for the sessions are available
through in-kind contributions from Kidstar.

INDIRECT COSTS ($0)

No indirect costs are budgeted.

IN-KIND CONTRIBUTIONS

Kidstar will provide space for treatment sessions and OTR/L administrative and evaluation
needs. Kidstar will supply use of a printer for handouts and worksheets (8 pages per child at
$0.15/page: 8x$0.15x140 = $168 value) and support staff for treatment sessions (4 hours per
week at $12/hour: 4x$12x52 = $2,496 value).

TOTAL BUDGET ($20,226)

Total Direct Costs: $20,226

Total Indirect Costs: $0

Total Budget (Direct + Indirect): $20,226

Appendix A: Needs Assessment - Parent Survey Results

Child has difficulty • Yes: 8

controlling emotions • No: 0
• Did not answer: 1

Child has difficulty • Yes: 6

expressing emotions • No: 2
• Did not answer: 1

Triggers for child becoming • Conflict with others (perceiving something as unfair,
out-of-control (open-ended being told no, turn-taking, an expectation not met, not
responses) getting attention)
• Lack of autonomy (feeling forced or controlled, asked to
do chores, asked to stop an activity, perceiving things as
being unfair)
• Environment (loud noise, large groups)
• School (refusal to do homework, classwork, follow set
school schedule)
• Feeling anxious or overwhelmed (being asked too many
things)
• Diet (eating high sugar foods)
• Nighttime routine
• Difficulty falling asleep and staying asleep through the
night
• Staying on task during household chores
• Seeking attention from others
• Wanting everything while shopping at a store

Coping skills currently used • Deep/calm breathing

(open-ended responses) • Taking a break/time away
• Quiet activity (writing, drawing, reading, playing the
piano, playing with cars)
• Physical activity (bike riding)
• Hugs
• Talking/reassurance from someone
• Distraction
• Sensory tool (Soft toys, weight, compression)

Interests (open-ended • Sports (basketball, kickball, bike riding, tumbling )

responses) • Music
• Quiet recreation (Lego, drawing, reading, games)
Occupation Average Level of Difficulty

Self-Care 2.44

Sleep & Nighttime Routine 2.83

Household Chores 3.33

Social Participation & Play* 2.63

School & Homework* 3.38

Community activities (i.e., shopping, church, 2.69

recreation) *

The following scale was used to measure difficulty in occupations: 1 - never difficult; 2 -
sometimes difficult; 3 - frequently difficult; 4 - always difficult.
*Only 8 of 9 parents responded to this question.

All parent surveys were collected on June 12, 2020; completed by 9 parents.
Appendix B: Needs Assessment - Kidstar Staff Survey Results

Strengths of Kidstar (open-ended ● Personnel

responses)
● Good team/comradery
● Having many people observe the kids to get
different perspectives
● Various groups (expressive therapy, recreation
therapy, social skills, growth mindset)
● Flexibility, adaptability, and individualization of
each patient’s treatment

Suggestions to enhance current ● Books (narratives) with activities

emotional regulation curriculum
● More handouts or manuals about emotional
(open-ended responses)
regulation
● More tools for “calm down” room and box

Times of day when children are most ● Last groups of the day
dysregulated (open-ended responses)
● Unstructured/free time

Understanding of sensory processing ● Average score = 2.5

The following scale was used to measure understanding of sensory processing: 1 - none; 2 -
some; 3 - good; 4 - in-depth.

All staff surveys were collected on June 12, 2020; completed by 2 staff members.
Appendix C: Social Emotional Evaluation (example question)
Appendix D: Sensory Profile 2 (example page)
Appendix E: Parent Outcome Survey (example questions)

Please rate how satisfied you were with the program in improving your child’s emotion
regulation.
1 - not satisfied 2 - somewhat satisfied 3 - very satisfied

Please rate how capable you feel in helping your child use emotional regulation skills.
1 - not capable 2 - somewhat capable 3 - very capable

What tools are working for your child when they need to change their zone?