Background and Demographics Alexander Mesa is a four year old, Hispanic, male. He was born four weeks premature at the conclusion of a high-risk pregnancy. His mother was a heavy drinker and diabetic. She did not have adequate healthcare, supplements or nutrition during her pregnancy. Alexander’s parents were separated throughout much of the pregnancy and his mother was working full time in a physically demanding job. His mother had an emergency cesarean leading to his premature birth. At birth Alexander was underweight but otherwise healthy. From infancy to toddlerhood he suffered from asthma and frequent ear infections, perhaps exasperated by his mother’s smoking. Alexander’s parents reunited after his birth and report that they have a great relationship. Both parents work full-time and frequently rely on various family members to transport Alexander to and from school. Alexander’s parents are demonstrative and bonded to their son but report being physically tired and stressed due to long shift work. Family members report financial concerns and other stressors in the home, including scheduling and supervision concerns during required shift work on nights and weekends. Alexander Mesa is a typically developing four-year-old boy. Physically, he is slightly above average for height and but average for weight. He does not exhibit any hearing, speech or vision deficits and is able to perform age-appropriate fine and gross motor activities. Likewise, he is able to perform age-appropriate cognitive tasks. Alexander can toilet, dress and eat independently. Alexander exhibits challenging behaviors in the classroom including task avoidance, physical aggression against peers, destructive behavior with furniture and toys, attention seeking behaviors, and exhibits distress during transitions and in response to loud noise or highly stimulating or unstructured activities and situations. When interviewed, Alexander stated he enjoys playing and watching sports with family members, especially basketball. Alexander noted that he takes karate with an uncle. In centers he consistently showed a preference for Legos and other manipulatives. During outdoor play Alexander rode bikes, climbed on the playground equipment and tire swing. Alexander frequently requests attention for his agility, speed, etc. During story and circle time Alexander always sits extremely close to the teacher without regard for personal space. Alexander enjoys attention from peers but especially adult attention as demonstrated by his verbal requests to “look at him” and physical proximity to others. Therapeutic Interventions Alexander has not yet been screened for, or receiv