Thursday, August 14, 2008

The effectiveness of the HowdaHUG seat in improving attending behaviors of preschool-aged children during circle time

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

The Product
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.

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.
Circle Time
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
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:

Independent variable:
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.

Dependent variable:
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.


Case-Smith, J. (2004). Continuing competency and evidence-based practice. Retrieved September 15 from

Edelson, S.M., Edelson, M., Kerr, D., & Grandin, T. (1998). Behavioral and physiological effects of deep pressure on children with Autism: A pilot study evaluating the efficacy of Grandin’s Hug Machine. American Journal of Occupational Therapy, 53, 145-152.

Fertel-Daly, D., Bedell, G., Hinojosa, J. (2001). Effects of a weighted vest on attention to task and self-stimulatory behaviors in preschoolers with pervasive developmental disorders. American Journal of Occupational Therapy, 55, 629-640.

Honaker, D., & Rossi, L. (2005). Proprioception and participation at school: Are weighted vests effective? Sensory Integration Special Interest Section Quarterly: American Occupational Therapy Association, Inc., 28(3), 1-4.

Howda Designz. (2007). About HowdaHUGS. Retrieved September 15, 2007 from

Olson, L.J., & Moulton, H.J. (2004). Use of weighted vests in pediatric occupational therapy practice. Physical & Occupational Therapy in Pediatrics, 23, 45-60.

Ottenbacher, K., & York, J. (1984). Strategies for evaluating clinical change: Implications for practice and research. American Journal of Occupational Therapy, 38, 647‑659.

VandenBerg, N.L. (2001). The use of a weighted vest to increase on-task behavior in children with attention difficulties. American Journal of Occupational Therapy, 55, 621-628.

Friday, August 08, 2008

Update on continuing competency requirements for occupational therapists in New York State

Over two years ago I wrote this article about continuing competency regulations for occupational therapists in New York State. Based on a review of the status of proposed regulations for continuing comptency as reported by the New York State Assembly website - there has been no action on this bill and it seems to be 'stuck' in the Higher Education Committee.

The idea behind this proposed legislation would be to improve consumer protection by mandating that occupational therapy practitioners in New York State participate in some mandatory continuing education. As of right now, the therapist who is treating YOU in New York State may have graduated thirty years ago and never taken a continuing education course.

Interestingly, a law requiring physical therapy continuing education in New York State was signed by Governor Patterson only a month ago. Since that time I have scoured the Internet and NYSOTA website for word on the OT continuing education bill and have not found anything.

It is unfortunate that the OT bill could not have been combined with the physical therapy bill for continuing education. I am not sure if there were reasons why this could not happen - I have forwarded the question to NYSOTA and if they respond I will post the information here.

For now consumers of occupational therapy services are not as protected in New York State as they should be. The lack of consistency of continuing competency requirements on a state by state basis in the United States underscores the importance of the NBCOT model as a national standard for continuing competency.

Consumers and practitioners both need to lobby their State Senators and Legislators so that these bills can be moved out of committee and to the floor for voting.

Monday, August 04, 2008

ABC Therapeutics Occupational Therapy Weblog Reviews!

I thought this would be a fine opportunity to begin publishing snippets and reviews of my writing. This page will be dynamic and updated as new comments or reviews are received.

"...self agrandizing (sic) blah-blah."

- Dr. Jane Sorensen, 8/2/08, Advance for Occupational Therapy Practitioners website, regarding my comments on discussion regarding this article that she authored.

edit 10/10/08

This was a very flattering find at

The featured blog is ABC Therapeutics Occupational Therapy Weblog by Chris Alterio (who works in New York) and is in my opinion outstanding. Alterio’s writing is clear, intelligent and engaging crossing over from the nuances of clinical practice through theoretical discussions around diagnosis to the intricacies of neuroanatomy of clinical conditions. In this scholarly article on foster care, Alterio discusses its implications for occupational therapy and includes a comprehensive set of references (he adopts the same rigorous approach to a number of other articles). Alterio ponders the impact of events that are yet to happen, writes this terribly sad article about the death of a child (in the about section of the blog however Alterior writes that people in the blog are not mean to represent people in real life), or writes about his role as an expert witness on animal-assisted therapy, the role of physical modalities in OT, sensory processing disorder in DSM-V (which is followed up by further articles on this topic), the potential effects of social class on education, a fascinating article on Horner’s Syndrome and phenomenology and OT. There are many more interesting and varied articles and this blog gives helpful insights into occupational therapy which plays an important role in mental health services.

edit 2/18/09

Here was an interesting link that has apparently been out there for a while but someone just sent to me:

edit 9/21/10

Here are some comments that I ran across today:

"Chris Alterio writes this blog and does so very well. He has a good ear for a story and is generous with his time and knowledge, sharing insights backed up with book references for your own further reading. He has been blogging and using social media to build community and discussion for four years, as he points out in this article. Top of the list, and deservedly so."

edit 3/26/12

Here is an anonymous comment that was so great I wanted to include it:

"Initially I was interested because I am a true advocate for providing the HIGHEST quality of care, but I am extremely discouraged after reading the segment "about this blog's author." Unfortunately he presents as egotistical intelectual, simply seeking to initiate some notoriaty to achieve fame. I have the same degree as "said author" and I believe there is a way to impact change in the system, WITHOUT flaunting intellegence or degree.

Comment moderation has been enabled according to the blog author. I am completely aware that you (the blog author) will not submit my comment as written. Knowing this, I hope something I wrote will reach YOU. Since it OBVIOUSLY will not reach ANYONE else."

edit 4/17/12:

This was from Dr. Barbara Boucher at Therextras ( This was very kind:

"I have linked to Chris Alterio’s blog ABCTherapeutics often for his eloquent and succinct appraisal of occupational therapy practice. on every level – the child, the family, the law and reimbursement. I only hope you continue to find the time to blog, Chris."

edit: 10/30/13:

I haven't edited this entry in a while, but I got such an amusing comment today I needed to include it.  This is from "Kathy" who I really wish would share her full name.  :D

"Wow-you really need to do your research a little bit better. There is research documentation regarding sensory brushing protocol and Therapeutic Listening. The research you are looking for regarding Astronaut Training is in the manual, not on some weblink on the internet. The I have been an OT for 24 years, all specializing in pediatrics. It is sad that someone in our field is so negative about new techniques to use in our practice. I hope you are nearing retirement. We need people with more open minds in our field"

edit: 7/21/16:

This is one my favorites of all time, received from an anonymous reviewer on a manuscript I submitted for publication:

"I am less enthusiastic about this revision than the original manuscript...To me, your revision is superficial, naive and biased. Non-reflective therapists will breathe a sigh of non-reflective relief and say, "I don't have to change. I am loyal to my profession's roots." To me, your revision is scary and dangerous."

Friday, August 01, 2008

More on 'Who should we be treating in EI'

Here is a response from Dr. Sorensen, published on the Advance for OT website at

I would like to re-post her comments in full - even though my intent is entirely Fair Use - but I don't want to be squelched by powers who don't like the debate. Go to the link quickly before it disappears. If Dr. Sorensen would like to grant permission I will post her comments in full on this site.

Dr. Sorensen asks that people go to which she believes is an article that will 'validate your clinical experiences.' This article quotes several health care professionals who question the life-saving measures and efforts that are afforded to critically ill infants.

For the second time this week I am deeply disappointed in Dr. Sorensen's opinion.

This article is a gross misrepresentation of what happens on a daily basis in neonatal intensive care nurseries. The article suggests that parents who have premature babies secretly wish that they would just die, and that the professionals are forced by the government to provide care that they know is futile, painful, and ultimately cruel. I worked in a neonatal intensive care nursery and this is not what I saw at all.

Rather, I saw parents who were devestated that their child was born early and who desperately did anything they could to stay on bedrest, take prescribed medications, and pray that their baby wouldn't be premature. When their babies were born the parents were terrified at their fragile state and unable to grasp the enormity of what was necessary to keep them alive. They wanted their babies to live and to be healthy.

Doctors and nurses and therapists who love babies and love families did everything they could to provide highly technical and sophisticated care to save lives. They cycled the lights on and off in the nursery, tried to minimize unnecessary stimulation that was damaging to the baby's immature nervous systems, and tried to cluster their care so that the babies were not disturbed more than was needed.

Many premature babies come from at-risk families. Sometimes the baby's mother was a teenager who had taken drugs. The mother would be scared and wouldn't know what to do so the hospital staff worked extra hard to teach the young girl what it would mean to be a parent and how to care for their baby.

Although it was infrequent, sometimes a baby would be too sick and just have too many problems. Doctors and parents conferred. Cases would be referred to the hospital ethics committee. Agonizing decisions would be made by parents. Sometimes parents and hospital staff would hold each other and cry together when a final choice was made to withold treatment.

The article that Dr. Sorensen quotes also states that all these children are a burden to their families and that the burden is worse because of a lack of governmental support. Since the so-called 'Baby Doe' Laws were passed there has also been significant legislation passed to create support networks - in fact the laws that mandated early intervention services were passed after the Baby Doe Laws. Undoubtedly the services to support child development are expensive and I have mentioned previously we do need to use our resources wisely and efficiently - but to say that these children are an incredible burden and that there is no support for families is grossly incorrect.

Rather, parents of premies or of other babies who have developmental problems still love their children. Just like every other parents they want the best for their children and will generally go to any length possible to do whatever their children need. My experience in early intervention is that parents feel blessed with their children - not burdened.

Some families have fewer resources and need more support and education. It is our responsibility as a compassionate society and as compassionate therapists to provide that support - not spread false information about how the children would be better off dead.

Early intervention services are important for children and families. The services are expensive and as responsible professionals we need to advocate for efficiency and conduct research so that we know what methods and service delivery models deliver the best results. Many studies have already been done and every day therapists use this information to provide the most effective and efficient services possible.

Improving delivery systems is always a need and of course it is a frequent topic in my blog. Dr. Sorensen's approach is to solve the problem through amputation - literally throwing out the baby instead of changing the bath water. At any time there will be a sad anecdotal story of an overwhelmed parent who is unable to cope with an overwhelming situation. I suppose it might also be easy to find a professional who feels like Sisyphus after spending long and frustrating days of trying to teach parenting skills to seemingly disinterested teenagers.

The answer to the tired parent and the frustrated professional is usually found the next day after a good sleep. The next day the parent will see the baby smile and reach a little farther and finally be able to play with the toy. The therapist will hear a mother say, "Today you really helped me understand things - thank you for caring and for helping my baby." And at the end of that day, even though there is no knowledge of what the next day will bring, a little bit of hope is created. Maybe it is enough to last just an hour. Maybe it will carry through the whole next day.

But it will be hope. And it will be good. And that is why we work with children and their families.