Scoping Review of Self-Regulation: What Are Occupational Therapists Talking About?

Procedures

The present scoping review included four steps: (1) searching for relevant publications; (2) selecting publications on the basis of predefined inclusion criteria; (3) extracting data; and (4) collating, summarizing, and reporting results (Arksey & O’Malley, 2005; Levac et al., 2010). Although the process seems linear, the actual course of the review is generally iterative, with previous steps revisited as needed.

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram in Figure 1 represents the process undertaken in the present review. For the current study question, the following databases were used: OTseeker, CINAHL, Scopus, PsycINFO, Embase, ERIC, and Medline. A search strategy was developed to define key words for all searches. For example, the Medline search strategy used was exp Psychology/ or Audiology/ or Speech–Language Pathology/ or (Human adj2kinetics).tw. or Occupational Therapy/ or Physical Therapy Specialty/ or Rehabilitation/ or Nursing/ or Education/ and [(self adj regulat^*).tw. or (meta adj cognit^*).tw.], limit to (English or French or Italian). No beginning date was identified, and the cutoff date was March 2014. Language inclusion criteria were limited to English, French, and Italian, with no other publication restrictions. All references were entered into a RefWorks file for processing (N = 1,804).

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Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of articles identified, included, and excluded.

The original search captured 1,496 unique publications after duplicates were removed. These publications were evenly divided among the first three authors (Martini, Cramm, and Egan). At each step of the screening process, two of the three authors independently reviewed articles to determine inclusion. When disagreement occurred over study inclusion, the other author acted as a tie-breaker. The first screening round consisted of reviewing titles, authors, and abstracts. Full texts of articles were included for the second screening round if they contained the root terms occupational therapy and self-regulation in the title, key words, or abstract. This search resulted in 93 unique publications. These articles were then included for full review if at least one of the authors was an occupational therapist and if the publication included the term self-regulation. Articles were excluded if none of the authors was an occupational therapist or if the term self-regulation was not present or was used in relation to professional regulation. Editorials that introduced an article that included self-regulation and book chapters were also not included. Finally, only publications written in English were included.

Of the 93 publications identified from the review of abstracts, 35 were excluded (13 without an occupational therapist as an author, 11 that did not mention self-regulation, 5 concerning professional self-regulation, 1 thesis that was already described in an included article, 1 editorial describing an included article, 2 articles written in German, and 2 book chapters) and 58 were included. In reviewing the articles and their reference lists, an additional publication was identified, a book, and added to the already included publications.

The research team developed a data charting form to obtain key information from the 58 publications to be able to apply a common analytical framework. The identification of the data to be charted was an iterative process. As data charting proceeded, the team refined the extraction guide, testing it with parallel independent charting. They then met to determine whether the data charted were consistent across researchers. Once consistency was confirmed, two researchers (Martini and Egan) proceeded with the data charting for the rest of the publications. The following key items of information were identified and charted: author, year, type of publication, aim of study, population of concern, implicit and explicit definitions of self-regulation, assessment of self-regulation, interventions addressing self-regulation, associated outcomes, guiding theoretical framework, what is the focus of change, how is the change brought about, and who is initiating the change.

Data Analysis

To examine trends in the use of the term self-regulation in occupational therapy, data were analyzed quantitatively and qualitatively. Quantitatively, two frequency distributions were constructed. In the first, the number of articles in which self-regulation was mentioned was plotted over time. In the second, the number of articles by age group referred to was plotted, and the number of research versus practice papers was indicated.

Using thematic qualitative content analysis, two members of the research team (Martini and Egan) examined the charted data of the 58 articles regarding how the term self-regulation was used in each article (Arksey & O’Malley, 2005; Levac et al., 2010). First, explicit definitions were identified when present. When no explicit definition was provided, an implicit definition was determined on the basis of cited references or descriptions of the process and outcome of described interventions. Codes were then grouped into emergent categories. Once categories were generated, another member of the research team (Cramm) confirmed the themes and the classification of publications within these themes.

Definitional Ambiguity

The concept of self-regulation is complex. The ambiguity of this concept has been reported in education (Dinsmore et al., 2008) and in psychology (Bloch, Moran, & Kring, 2009). Our scoping review indicates that a lack of clarity is also evident within occupational therapy. Several factors contribute to this lack of clarity. First, this analysis of 58 publications shows that more than half of the occupational therapist authors who used the term self-regulation did not provide an explicit definition of the term. A similar finding was noted by Dinsmore et al. (2008) in their analysis of 255 studies in education; they found that when researchers used the term self-regulation they either provided no definition of the concept, misidentified the concept, or incorrectly operationalized the concept (Kaplan, 2008). The term self-regulation was used interchangeably with the terms metacognition and self-regulated learning or, in some cases, the two terms were embedded within each other (Lajoie, 2008).

Second, the influence from other domains is notable; our analysis identified four different theoretical frameworks that have guided the use of the term self-regulation in the occupational therapy literature. Further examination indicates that these frameworks seem to align with both the neobehavioristic orientation and the cognitive orientation described by Dinsmore et al. (2008). Three of the four theoretical frameworks used by occupational therapists (synactive theory of development, sensory integration, and cognitive–behavioral theory) principally target internal, unobservable processes. The study of self-regulation guided by the fourth theoretic framework, self-regulation theory, tends to target task learning or accomplishment, a more observable process.

When a definition of self-regulation was provided, definitions subsumed within the synactive theory of development referred to regulation of processes such as autonomic functions and arousal (e.g., Grenier et al., 2003). Within a sensory integration framework, definitions in publications on toddlers referred to abilities to regulate responses to stimuli (e.g., Roberts et al., 2007; Tirella & Miller, 2011) and definitions in publications on school-age children referenced controlling emotions and behaviors as well as self-recognition of feelings (e.g., Cyzner, 2000). Definitions derived from self-regulation theory tend to refer to a more cognitive process and an outcome such as acquisition or learning (e.g., Hyland & Polatajko, 2012; Paquette et al., 2013).

Several publications that did not identify a theoretical framework did provide a definition. These articles most often included a conscious or cognitive element and referred to monitoring of performance or behavior. The variety of elements included in the different definitions attest to the influence of the various theoretical frameworks. Such a variety in the conceptualization of the term is also present in the publications in which a definition was not provided.

Implicit Levels of Strategy Use

The process of self-regulation entails the application of strategies. Another source of ambiguity when considering conceptualizations of self-regulation in occupational therapy seems to be that most publications refer to strategy as a single common notion. When it comes to self-regulating behavior, the present examination seems to indicate two levels of strategy: (1) those focused on arousal or emotional state and (2) those focused on thinking.

In the first level of strategy use, when authors refer to self-regulation, the aim is to influence behavior through changing physiological or emotional arousal. These strategies act as a catalyst that brings about a change in emotion or arousal, which will in turn foster a change in behavior. The applications of these catalyst strategies tend to be initiated by certain internal states (e.g., low level of arousal) or emotion (e.g., anxiety). These strategies can be initiated by others or self-initiated. When they are initiated by another person (e.g., swaddling a baby, providing a weighted vest to a child), it is usually with younger populations (e.g., toddlers) or populations with potentially compromised cognitive ability (e.g., people with autism). In addition, in these cases, the strategies tend to be guided by the synactive theory of development or the sensory integration framework. When these strategies are self-initiated (e.g., positive self-talk), they are usually within a cognitive–behavioral framework and used by adults or older children.

The second level of strategy use is focused on thinking and has been labeled metacognitive (Flavell, 1979). This “thinking about thinking” guides strategy selection or problem-solving processes. Because metacognitive strategies involve thinking, they are always self-initiated; in the literature we identified, they were always used by an adult or older child. Metacognitive strategies are found in the self-regulation process described within self-regulation theory and are applied to task learning and accomplishment. They are also found in cognitive–behavioral theory, in which they are used to monitor the application of strategies aimed to regulate internal behavior such as emotion.

In our examination of the use of self-regulation within the sensory integration theory framework in populations older than babies and toddlers (e.g., school-age children), we found that authors tended to describe both the application of strategies focused on arousal or emotion (initiated by others or by self) and the application of metacognitive strategies to provide insight on the emotional or sensory state (e.g., level of alertness; feelings of anger, frustration, stress) so that the input from the environment can be modified (e.g., use headphones to listen to music, hand fidgets or putty, wall push-ups) to alter the level of arousal or emotional state (i.e., strategies aimed at the emotional or sensory level). In these situations, the authors simply referred to self-regulation and did not differentiate between the functions of strategy application that were present, that is, the metacognitive strategy to guide the strategy selection (when and what catalyst strategy to use) and the catalyst strategy applied that would precipitate the change in sensory or emotional state. This approach leads to confusion because it not clear whether self-regulation refers to the process of applying a strategy to change the sensory and, by extension, emotional state or to the metacognitive process of strategy selection and application.

Consistency of Theoretical Framework and Strategy Level

In occupational therapy, self-regulation refers to several concepts. Note that the term has relatively consistent meaning when applied to work with infants and adults. However, when used to describe work with children, there is a fair amount of variation that seems to be influenced by the underlying theoretical frameworks. Although there are several reasons to ensure a clear conceptualization of the term, an important one is communicating a logical connection to an underlying theoretical framework, which is critical in practice, research, and education.

First, without reference to an underlying theoretical framework, from an intervention perspective, it is challenging to select and defend the use of particular self-regulation strategies. As clinicians, it is important that practitioners understand strategies conceptually. With such an understanding, the practitioner can appreciate the hypothesized mechanism of action of the intervention and the expected results. Understanding the mechanism of action ensures that methods are applied appropriately and can be adapted, when necessary, in a manner that still supports the outcome. Understanding the expected results makes it possible to clearly communicate them to clients and evaluate therapeutic effectiveness appropriately.

For example, in the synactive theory of development, in which self-regulation strategies aim to change physiological arousal (e.g., noted by flailing limbs and arching of back in premature babies), the effectiveness of the strategy (e.g., swaddling to maintain flexion) is determined by evaluating change in physiological arousal (e.g., infant’s sleep will be organized, agitation prevented). In the self-regulation theory framework, the strategies aim to guide a self-monitoring or problem-solving process (e.g., self-assessing performance, such as driving or throwing a ball, and changing the time of driving or ball-throwing technique accordingly). In these cases, the effectiveness of the self-regulation strategy would be ascertained by evaluating whether the client did self-assess and change when he drives or how he throws the ball.

When self-regulation strategies appear to be aimed at two levels, as previously described, it is important to evaluate the effectiveness of each level of strategy. For instance, in the ALERT Program, which is guided by sensory integration theory, Williams and Shellenberger (1996) referred only to self-regulation strategies, but they appeared to be alluding to two levels of strategy. The first level consists of catalyst strategies (e.g., manipulating a stress ball, listening to quiet music), which aim to change the sensory or emotional state (e.g., frustration, arousal). The second level consists of metacognitive strategies, which encourage the child to self-monitor frustration or arousal level. To evaluate the first level, practitioners might ask, “Does the child’s use of music calm him?”; to evaluate the second level, practitioners might ask, “Is the child able to self-monitor his arousal level?” “Is the child able to select an appropriate catalyst strategy?”

Table 2 presents the different theoretical frameworks identified in the occupational therapy literature search on self-regulation regarding the two levels of strategy application (catalyst and metacognitive) and the two types of initiation (by others and by self). This table demonstrates conceptual confusion because sensory integration theory can appear in all applicable quadrants, that is, within both levels of strategy application and both types of initiation.

Second, from a research perspective, clear conceptualization of self-regulation and related concepts is essential for the development and refinement of occupational therapy interventions. Rigorous definitions of these concepts and an understanding of their relationship to each other are critical to developing a body of knowledge that demonstrates the validity of occupational therapy theories and the effectiveness of resulting procedures. Similarly, occupational therapy practitioners will be able to make use of advances from other fields only if they appreciate how the understanding of these concepts aligns with or differs from other fields. Conversely, lack of such understanding would make it difficult to translate occupational therapy research to other disciplines. For example, research in education can provide helpful information regarding the use of metacognitive strategies when occupational therapy defines self-regulation in terms of these strategies. Moreover, psychology research on sensory processing would be useful regarding the regulation of internal behaviors such as degree of sensory or emotional arousal when occupational therapy defines self-regulation in these terms.

Finally, from an education perspective the lack of conceptual clarity regarding self-regulation limits opportunities for students to fully understand how such occupational therapy interventions produce change and which changes they might logically produce. Therefore, an understanding of the underlying framework that guides strategy use in the self-regulation process is necessary.

Future Research

Several critical issues should be considered when engaging in research that encompasses the concept of self-regulation to ensure that it leads to theoretically valid and replicable outcomes. First, researchers should not assume that readers, whether they are clinicians, researchers, or educators, will know what self-regulation is. Lack of adequate definitions of essential concepts in research articles frequently causes confusion for readers trying to understand research results (Lajoie, 2008). Inconsistent definitions of essential concepts across studies often contribute to conflicting research results (Schunk, 2008). Although imposing one common definition is neither realistic nor desirable, it is reasonable and necessary for researchers to clearly define the term self-regulation when communicating their research results.

Second, researchers need to explicitly reference the theoretical frameworks that guide their research in self-regulation. As noted in this scoping review, in the occupational therapy domain, the study of self-regulation is guided by several theoretical frameworks, each with its own set of constructs and conception of self-regulation. The concept and definition of self-regulation is derived from the theoretical framework, so it is only by explicitly recognizing the relevant constructs that the vision, structure, and direction of the study can be properly understood. It permits the researcher to appropriately determine the relevant variables to explore, identify the outcomes to measure, and provide a context for the interpretation of results.

Finally, the aims of self-regulation strategies should be specified. The fact that self-regulation is applied in different domains and at different levels contributes to the complexity and confusion related to this concept. Although indicating the theoretical framework may be helpful in clarifying the domain in which the term is being used, as we have seen from our review, it may not provide clarity regarding the level at which strategies are being used, making it difficult to determine the appropriate variables or outcomes on which to focus.

Limitations

This scoping review has several limitations. There is always the possibility that literature may have been missed despite the search strategy and process being conducted with the support of an experienced research librarian (Lindsey Sikora). A certain level of inherent subjectivity is inevitable in the decision-making process when considering inclusion and exclusion of studies and in conducting the thematic analysis. To address the issue of bias in the study selection, all decisions were made independently by two reviewers, and a third reviewer acted as a tiebreaker. A similar process was undertaken for the data charting process. Finally, to reduce subjectivity in the thematic analysis, themes were derived by two reviewers and later verified by a third reviewer.