What They Did

Self-regulation is something most of us are supporting in primary schools, and something I have already presented on as it is my PhD topic. Cossart and colleagues noticed that despite this clear interest, very little literature specifically examines how occupational therapists understand and apply self-regulation as a concept when working in mainstream primary schools.

The scoping review builds on three earlier scoping reviews, published in 2016, 2023 and 2024, which found that occupational therapists don’t have a consistent, occupationally grounded way of measuring self-regulation, and there’s no clear consensus on how to define it. Cossart and colleagues wanted to build on this by focusing specifically on the primary school environment, asking one research question: how do occupational therapists understand self-regulation in the primary school setting?

Methods

The authors searched five databases following the JBI scoping review methodology and PRISMA-ScR reporting guidelines, with no restriction on publication date. The peer-reviewed studies were published between 2016 and 2022, from Australia, Canada, the USA, Spain and Belgium, with sample sizes ranging from just 11 teachers up to 288 children. Given how few peer-reviewed papers were found, the authors chose to include dissertations too, this is not uncommon in scoping reviews which can include grey literature. A total of 12 papers met the inclusion criteria: seven peer-reviewed papers and five dissertations. 

Importantly, this review only included studies where occupational therapists were the ones planning and delivering the intervention, and it deliberately excluded papers focused on specific diagnoses like autism or developmental coordination disorder, to keep the focus on generalised, whole-school self-regulation support rather than disability-specific practice.This is why it has a lower number of papers and different results to the previous reviews.

The Results

Self-regulation is inconsistently defined. When a definition was given, self-regulation was generally described as an active process involving control and modulation to achieve a goal. When it wasn’t defined outright, related terms were used instead, such as self-regulated learning, emotional self-efficacy, or social competence. Social-emotional learning and executive functioning appeared far more often in these papers’ introductions than self-regulation, and sensory processing was mentioned only once across all seven peer-reviewed papers.

Self-regulation was rarely the actual research focus. None of the peer-reviewed papers named self-regulation directly in their research aim or question. Instead, studies focused on related constructs, like executive function or social-emotional skills, or on evaluating a named programme.

Structured programmes dominated the intervention approaches. The Alert Program® was the most cited, with one included paper reporting that around half of school-based occupational therapists in the US use it. Zones of Regulation® also featured prominently. One study used occupational performance coaching.

Self-regulation wasn’t directly measured by any peer-reviewed paper. Instead, a wide range of standardised tools were used to measure related constructs, such as the Behaviour Rating Inventory of Executive Function, the Canadian Occupational Performance Measure, Goal Attainment Scaling, and various behaviour rating scales, mostly capturing either body structures and functions, or activities and participation, domains of the ICF.

Practical Takeaways

The clearest message here is that self-regulation remains a fairly ambiguous concept, worth reflecting on in your own practice. If we can’t clearly articulate what we mean by self-regulation, or how it relates to occupational performance, it becomes harder to communicate our distinct contribution to teachers and school leadership.

The heavy overlap with executive functioning and social-emotional learning is also worth noting. It’s a useful prompt to be explicit, both in documentation and in conversations with schools, about what makes an occupational lens on self-regulation different, for example its grounding in sensory processing and everyday participation, rather than a purely cognitive or behavioural framing.

If you’re using programmes like the Alert Program or Zones of Regulation, it’s worth remembering that the evidence base for these specific programmes remains limited, so pairing programme delivery with individualised, occupation-focused outcome measurement is likely to strengthen your practice.

For me, this study aligns with what I am seeing in my own PhD work, that self-regulation is inconsistently conceptualised not just in OT, but across and within all disciplines. And it provides further evidence that we need to work together with our education, psychology and allied health colleagues to reach agreement on what we are talking about in practice.

This small pilot study looked at whether a 16-session, eight-week movement-based programme, combining yoga, beat-synchronisation and mindfulness, improved sustained attention in first-grade students. Seven children completed pre- and post-testing using the Sustained Attention to Response Task and a teacher-completed behaviour questionnaire. Errors on the attention task fell from an average of 8.71% to 3.86%, though this didn’t reach statistical significance, largely down to the very small sample. Reaction times improved slightly, and observational journaling noted less fidgeting and fewer self-deprecating comments at post-test, while teacher-rated effortful control showed a small decrease, which the authors suggest may reflect the subjective nature of teacher report rather than a genuine change in the children. For me, the obvious limitation is the lack of a control group alongside that tiny sample, so it’s hard to separate programme effects from simple maturation, but it’s a reasonable addition to the small evidence base supporting movement-based, Tier 1 classroom approaches to help with attention.

This scoping review covered 58 studies published between 2019 and 2024, covering approaches like mental health literacy, mindfulness, positive psychology, CBT and social-emotional learning. It mapped potential harms from universal, whole-class school-based mental health programmes for adolescents. Nearly a third of studies, 17 of 58, reported at least one type of potential harm, including statistically significant deterioration in outcomes across the whole sample, deterioration within specific subgroups such as younger adolescents, clinically meaningful deterioration for individuals, and harms raised through qualitative feedback or safety protocols. None of the included studies had prespecified harm as an outcome to measure, which the authors flag as a gap across the field. This paper provides a useful reminder for anyone involved in selecting or supporting whole-class wellbeing or self-regulation programmes: even well-intentioned universal interventions can have unintended negative effects for a subset of participants, so building in some form of monitoring is worth considering. I think it’s particularly timely given the shift to universal provisions and expectations on schools to be providing more support onsite. I’d also actually love to see the same review completed with Tier 1 interventions, as I think there is some assumption here that they do not cause harm. In my mind, these results would be more powerful if we could compare potential harms across all tiers of service delivery.