Ingredients Of Interventions Research Articles

In Vivo Feedback Predicts Parent Behavior Change in the Attachment and Biobehavioral Catch-up Intervention

Understanding mechanisms and active ingredients of intervention is critical to training clinicians, particularly when interventions are transported from laboratories to communities. One promising active ingredient of parenting programs is clinicians’ in vivo feedback regarding parent–child interactions. The present study examined whether a form of in vivo feedback, in the moment commenting, predicted treatment retention and parent behavior change when the Attachment and Biobehavioral Catch-up (ABC) intervention was implemented in a community setting. Observational data were collected from 78 parent–child dyads (96% mothers; M age = 29 years; 81% minority; infants’ M age = 12 months; 90% minority) across 640 sessions conducted by 9 clinicians (100% female, M age = 39; 67% minority) in Hawaii. Parental behavior was assessed with a semistructured play task before and after intervention. Clinicians’ in-the-moment feedback to parents was assessed from intervention session videos. Clinicians’ frequency and quality of in-the-moment feedback predicted change in parental intrusiveness and sensitivity at posttreatment. Frequency of in-the-moment feedback also predicted likelihood of retention. Hierarchical linear modeling demonstrated strong support for these associations at the between-clinician level, and limited additional support at the within-clinician (i.e., between-case) level. Thus, a hypothesized active ingredient of treatment, in-the-moment feedback, predicted community-based ABC outcomes. The results complement lab-based evidence to suggest that in vivo feedback may be a mechanism of change in parenting interventions. Helping clinicians to provide frequent, high-quality in vivo feedback may improve parenting program outcomes in community settings.

Therapist and client discussions of drinking and coping: a sequential analysis of therapy dialogues in three evidence-based alcohol use disorder treatments.

Research into the active ingredients of behavioral interventions for alcohol use disorders (AUD) has focused upon treatment-specific factors, often yielding disappointing results. The present study examines common factors of change in motivational enhancement therapy, cognitive-behavioral therapy and 12-Step facilitation therapy by (1) estimating transitional probabilities between therapist behaviors and subsequent client Change (CT) and Sustain (ST) Talk and (2) examining therapist skillfulness as a potential predictor of transition probability magnitude. Secondary data analysis examined temporal associations in therapy dialogues. United States: data were from Project MATCH (Matching Alcoholism Treatments to Client Homogeneity) (1997). One hundred and twenty-six participants who received motivational enhancement therapy, cognitive-behavioral therapy or 12-Step facilitation therapy. Therapist behaviors were measured in three categories (exploring, teaching, connecting) and client statements included five categories (CT-distal, ST-distal, CT-proximal, ST-proximal, neutral). Therapist skillfulness was measured using a five-point ordinal scale. Relative to chance, therapist exploratory behaviors predicted subsequent client discussion of distal, drinking behavior [odds ratio (OR)=1.37-1.78, P<0.001] while suppressing discussion of proximal coping and neutral content (OR=0.83-0.90, P<0.01). Unexpectedly, therapist teaching suppressed distal drinking language (OR=0.48-0.53, P<0.001) and predicted neutral content (OR=1.45, P<0.001). Connecting behaviors increased both drinking and coping language, particularly language in favor of change (CT OR=1.15-1.84, P<0.001). Analyses of exploring and connecting skillfulness revealed that high skillfulness maximized these behaviors effect on client responses, but not teaching skillfulness. In motivational enhancement therapy, cognitive-behavioral therapy, and 12-Step facilitation therapy for alcohol use disorders, the therapists who explore and connect with clients appear to be more successful at eliciting discussion about change than therapists who engage in teaching behavior. Therapists who are more skilled achieve better results than those who are less skilled.

Approaches to Cognitive Stimulation in the Prevention of Dementia

The prevalence of dementia and age-related cognitive impairment is rising due to an aging population worldwide. There is currently no effective pharmacological treatment, but cognitive activity programs could contribute to prevention and risk reduction. However, the results of intervention studies are inconclusive, which may be related to methodological issues. For example, the inconsistent use of umbrella categories to describe cognitive intervention strategies, such as cognitive training or cognitive rehabilitation, has led to confusion regarding their respective contents and efficacies. The interventions studied so far draw on a pool of common basic ingredients. Therefore, rather than focusing on a few high-level categories, it might be beneficial to examine the efficacy of more basic cognitive intervention ingredients, which form the building blocks of complex multi-strand cognitive intervention strategies. Here we suggested a novel format of collating basic cognitive intervention ingredients. Using a representative sample of review articles and treatment studies, we attempted to inventory the most commonly encountered ingredients. Finally, we discuss their suitability for individualized and group-based approaches, as well as the possibility for computerization.

Ingredients, outcomes and mechanisms of change in complex interventions for children with movement limitations: a systematic evidence synthesis

Method Two electronic databases (PEDro, OTSeeker) were searched using ‘child’, ‘paediatric’ OR ‘adolescent’, limiting years to 2000-2011. Records were included if participants were 0-18-years-old with movement impairments; intervention involved OT/PT; AND primary outcome related to the child’s activity/participation as specified by the WHO. Data were extracted on: study characteristics, intervention ingredients, intended outcome constructs, and hypothesised mechanisms. Two raters completed all screening and data extraction. Quantitative content analysis and descriptive statistics were used.

Why are some people more successful at lifestyle change than others? Factors associated with successful weight loss in the BeWEL randomised controlled trial of adults at risk of colorectal cancer.

BackgroundThe BeWEL (BodyWEight and physicaL activity) randomised controlled trial demonstrated that a weight management programme offered in the colorectal cancer screening setting was effective. However, the differential responses of participants to the programme were notable. This study aimed to explore the factors associated with success and to identify implications for future programme design.MethodsAnalyses were conducted of quantitative data (n = 148) from the BeWEL intervention group to compare demographic and psychosocial characteristics and lifestyle changes in those who met and exceeded the target 7 % weight loss (‘super-achievers’) with those who achieved only ‘moderate’ or ‘low’ amounts of weight loss (2–7 % loss, or <2 % loss, respectively). In-depth qualitative interviews (n = 24) explored in detail the motivations, actions, pathways to weight loss and circumstances of study participants.ResultsOver the 12 month intervention period, mean percentage weight loss of super-achievers (n = 33) was 11.5 %, compared with moderate-achievers (n = 58) who lost 4.2 %, and low-achievers (n = 57) who gained 0.8 %. Compared to other groups, super- achievers increased their fruit and vegetable intake (p < 0.01) and physical activity (step count, p < 0.01). ‘Super-achievers’ did not differ in baseline demographic characteristics from other participants. However, significantly fewer reported that their activities were limited by physical and emotional health and they were more likely to perceive their current diet as harmful. Qualitative analyses found no consistent patterns among super-achievers in relation to some factors identified as important in previous studies, such as social support. However, super-achievers shared several characteristics such as determination and consistency in their engagement with the intervention, receptivity to new information and prompts, previous positive experience of changing health behaviours, being motivated by early success, making changes routine, and an ability to devise and apply strategies for dealing with setback and ‘relapse’ triggers.ConclusionsSuccessful lifestyle change depends on active engagement as well as effective intervention ingredients. Weight loss interventions are likely to be more effective where they can adapt to participants’ differing characteristics and needs, while also providing core elements likely to build success.

Methods to improve joint attention in young children with autism: a review.

We provide an overview of studies in the past 10 years (2004–2014) that have aimed to improve joint attention (JA) in young children at risk for, or with, autism spectrum disorder. Thirteen randomized controlled trial (RCT) interventions were found, which received particular focus. Three studies used intervention methods with a developmental orientation and focused on caregiver-mediated methods. Others used combined developmental and behavioral approaches and delivered intervention via trained interventionists, caregivers, and teachers. Interventions ranged widely in density, both with respect to the amount of intervention delivered weekly and the total duration of intervention. Fourteen single-subject research design (SSRD) studies and one quasi-experimental pre–post design study were also included. Notably absent in the RCTs were studies using only behavioral methods, while behavioral methods dominated in the SSRDs. The outcomes of the RCTs using combined behavioral and developmental methods generally demonstrate short-term social communication gains. While some studies demonstrated long-term maintenance and positive outcomes in related areas such as language, many did not. The mixed results for language outcomes indicate a need for further investigation. In addition, future studies should further examine participants’ developmental readiness and intervention dose in relation to outcome, as well as aim to isolate active ingredients of interventions.

P1111 : Variables associated with alcohol relapse and psychosocial interventions to prevent alcohol relapse in liver transplant patients for alcoholic liver disease: A systematic review

Background and Aims: Liver transplantation is the primary treatment choice for alcohol liver disease. However, alcohol relapse is a particular problem for this population with a reported 10–50% risk. This review aims to identify alcohol relapse variables, and establish the effectiveness and explore the active ingredients of psychosocial interventions in preventing alcohol relapse, in alcohol liver disease patients pre or post-liver transplant. Methods: Mixed method systematic review involving three parallel syntheses: (1) alcohol relapse variables; (2) psychosocial intervention effectiveness; (3) active ingredients of these psychosocial interventions (i.e. a component analysis). Medline, CINAHL, EMBASE, and PsychInfo were searched in November 2013 for published literature. Grey literature searched in Web of Science, Clinical Trials Register, and Electronic Theses Online Service. Synthesis 1: Systematic search for and appraisal of prospective studies, retrospective studies, and cross-sectional surveys. Syntheses 2/3: Systematic search for and appraisal of ‘randomised controlled trials’, ‘controlled before and after studies’, and ‘before and after studies in a single group’. Results: 23 papers included: 10 cohort, 11 case–control, 1 qualitative, and 1 randomised controlled trial. Five variables out of nineteen were alcohol relapse predictors (i.e. Synthesis 1): (1) <12 months pre-transplant abstinence; (2) presence of children; (3) poor pre-transplant psychosomatic evaluation; (4) non-compliant with post-transplant treatment plan; (5) active insurance policies at transplant. One psychosocial intervention paper did not report treatment effectiveness (i.e. Synthesis 2). The remaining three papers reported relapse rate reduction: Alcohol Addiction Unit (odds ratio 0.23), Structured Management (odds ratio 0.32), pre- and post-transplant Substance Abuse Treatment (odds ratio 0.27 compared to no substance abuse treatment; odds ratio 0.23 compared to pretransplant substance abuse treatment only). With confidence intervals not reported, the uncertainty level around the odds ratio is unclear. Furthermore, a theoretical basis was not discussed; thus, the active ingredients could not be identified (i.e. Synthesis 3). Conclusions: Randomised controlled trials to further investigate the predictive validity of the five main variables and ascertain the long-term benefits of the tentative yet promising results of the most effective intervention i.e. structured management.

Reporting on Interventions: Issues and Guidelines for Rehabilitation Researchers

Observers commonly note the poor reporting of research, including rehabilitation research. The Consolidated Standards of Reporting Trials (CONSORT) checklist (supplemented by the CONSORT extension for nonpharmacologic interventions) has been published for improving the reporting of intervention research. However, the items on these checklists are considered to be inadequate to guide authors as to which information to include when reporting on the intervention(s) studied, and the Template for Intervention Description and Replication, Journal Article Reporting Standards, and the checklist of the Western Journal of Nursing Research are recommended to rehabilitation researchers. The Rehabilitation Treatment Taxonomy framework is recommended as a conceptual scheme to assist authors in thinking through the linkages between intervention ingredients, targets of treatment, and the mechanisms of action linking these 2 areas. Recommendations are made for prospective authors and journal editors who desire to see improved reporting of rehabilitation interventions.

Applying the behaviour change technique (BCT) taxonomy v1: a study of coder training.

Behaviour Change Technique Taxonomy v1 (BCTTv1) has been used to detect active ingredients of interventions. The purpose of this study was to evaluate effectiveness of user training in improving reliable, valid and confident application of BCTTv1 to code BCTs in intervention descriptions. One hundred sixty-one trainees (109 in workshops and 52 in group tutorials) were trained to code frequent BCTs. The following measures were taken before and after training: (i) inter-coder agreement, (ii) trainee agreement with expert consensus, (iii) confidence ratings and (iv) coding competence. Coding was assessed for 12 BCTs (workshops) and for 17 BCTs (tutorials). Trainees completed a course evaluation. Methods improved agreement with expert consensus (p < .05) but not inter-coder agreement (p = .08, p = .57, respectively) and increased confidence for BCTs assessed (both p < .05). Methods were as effective as one another at improving coding competence (p = .55). Training was evaluated positively. The training improved agreement with expert consensus, confidence for BCTs assessed, coding competence but not inter-coder agreement. This varied according to BCT.

Association of behaviour change techniques with effectiveness of dietary interventions among adults of retirement age: a systematic review and meta-analysis of randomised controlled trials.

BackgroundThere is a need for development of more effective interventions to achieve healthy eating, enhance healthy ageing, and to reduce the risk of age-related diseases. The aim of this study was to identify the behaviour change techniques (BCTs) used in complex dietary behaviour change interventions and to explore the association between BCTs utilised and intervention effectiveness.MethodsWe undertook a secondary analysis of data from a previous systematic review with meta-analysis of the effectiveness of dietary interventions among people of retirement age. BCTs were identified using the reliable CALO-RE taxonomy in studies reporting fruit and vegetable (F and V) consumption as outcomes. The mean difference in F and V intake between active and control arms was compared between studies in which the BCTs were identified versus those not using the BCTs. Random-effects meta-regression models were used to assess the association of interventions BCTs with F and V intakes.ResultsTwenty-eight of the 40 BCTs listed in the CALO-RE taxonomy were identified in the 22 papers reviewed. Studies using the techniques ‘barrier identification/problem solving’ (93 g, 95% confidence interval (CI) 48 to 137 greater F and V intake), ‘plan social support/social change’ (78 g, 95%CI 24 to 132 greater F and V intake), ‘goal setting (outcome)’ (55 g 95%CI 7 to 103 greater F and V intake), ‘use of follow-up prompts’ (66 g, 95%CI 10 to 123 greater F and V intake) and ‘provide feedback on performance’ (39 g, 95%CI −2 to 81 greater F and V intake) were associated with greater effects of interventions on F and V consumption compared with studies not using these BCTs. The number of BCTs per study ranged from 2 to 16 (median = 6). Meta-regression showed that one additional BCT led to 8.3 g (95%CI 0.006 to 16.6 g) increase in F and V intake.ConclusionsOverall, this study has identified BCTs associated with effectiveness suggesting that these might be active ingredients of dietary interventions which will be effective in increasing F and V intake in older adults. For interventions targeting those in the peri-retirement age group, ‘barrier identification/problem solving’ and ‘plan for social support/social change’ may be particularly useful in increasing the effectiveness of dietary interventions.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-014-0177-3) contains supplementary material, which is available to authorized users.

Psychosocial treatments for individuals with autism spectrum disorder across the lifespan: new developments and underlying mechanisms.

Researchers have studied many interventions to address the core impairment in social interactions in autism spectrum disorder. We reviewed the social skills intervention literature over the past two years (2012-2014). Social skills intervention studies have increased by 35% over our previous review of 2010-2012. Nearly equal numbers of studies reported results using single subject research designs (n = 29) and group designs (n = 25). Consistent with our previous review, many studies focused on joint attention/joint engagement for young children and interventions addressing peer interactions for older children. Advancements in this review period included more replications of intervention models, longitudinal outcomes, and a focus on minimally verbal children. Notably absent are social interventions for adults, and interventions addressing school-based inclusion. In addition to these target areas, future studies should isolate active ingredients of social interventions, include broader participant representation, and further examine the relation between neural development and behavioral outcomes.

Interpersonal style should be included in taxonomies of behavior change techniques.

Interpersonal style should be included in taxonomies of behavior change techniques.

Ingredients of Successful Interventions to Improve Medication Adherence

Ingredients of Successful Interventions to Improve Medication Adherence

Usage of a Generic Web-Based Self-Management Intervention for Breast Cancer Survivors: Substudy Analysis of the BREATH Trial

BackgroundGeneric fully automated Web-based self-management interventions are upcoming, for example, for the growing number of breast cancer survivors. It is hypothesized that the use of these interventions is more individualized and that users apply a large amount of self-tailoring. However, technical usage evaluations of these types of interventions are scarce and practical guidelines are lacking.ObjectiveTo gain insight into meaningful usage parameters to evaluate the use of generic fully automated Web-based interventions by assessing how breast cancer survivors use a generic self-management website. Final aim is to propose practical recommendations for researchers and information and communication technology (ICT) professionals who aim to design and evaluate the use of similar Web-based interventions.MethodsThe BREAst cancer ehealTH (BREATH) intervention is a generic unguided fully automated website with stepwise weekly access and a fixed 4-month structure containing 104 intervention ingredients (ie, texts, tasks, tests, videos). By monitoring https-server requests, technical usage statistics were recorded for the intervention group of the randomized controlled trial. Observed usage was analyzed by measures of frequency, duration, and activity. Intervention adherence was defined as continuous usage, or the proportion of participants who started using the intervention and continued to log in during all four phases. By comparing observed to minimal intended usage (frequency and activity), different user groups were defined.ResultsUsage statistics for 4 months were collected from 70 breast cancer survivors (mean age 50.9 years). Frequency of logins/person ranged from 0 to 45, total duration/person from 0 to 2324 minutes (38.7 hours), and activity from opening none to all intervention ingredients. 31 participants continued logging in to all four phases resulting in an intervention adherence rate of 44.3% (95% CI 33.2-55.9). Nine nonusers (13%), 30 low users (43%), and 31 high users (44%) were defined. Low and high users differed significantly on frequency (P<.001), total duration (P<.001), session duration (P=.009), and activity (P<.001). High users logged in an average of 21 times, had a mean session duration of 33 minutes, and opened on average 91% of all ingredients. Signing the self-help contract (P<.001), reporting usefulness of ingredients (P=.003), overall satisfaction (P=.028), and user friendliness evaluation (P=.003) were higher in high users. User groups did not differ on age, education, and baseline distress.ConclusionsBy reporting the usage of a self-management website for breast cancer survivors, the present study gained first insight into the design of usage evaluations of generic fully automated Web-based interventions. It is recommended to (1) incorporate usage statistics that reflect the amount of self-tailoring applied by users, (2) combine technical usage statistics with self-reported usefulness, and (3) use qualitative measures. Also, (4) a pilot usage evaluation should be a fixed step in the development process of novel Web-based interventions, and (5) it is essential for researchers to gain insight into the rationale of recorded and nonrecorded usage statistics.Trial RegistrationNetherlands Trial Register (NTR): 2935; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2935 (Archived by WebCite at http://www.webcitation.org/6IkX1ADEV).

Treatment Fidelity in Early Childhood Special Education Research

Although this special issue on treatment fidelity is extremely timely for the field of early childhood special education (ECSE), this issue comes somewhat late in the history of conversations about the importance of information about treatment implementation. In 1980, Billingsley, White, and Munson discussed the need for treatment fidelity reliability in single case design studies. Blase, Fixsen, and Phillips (1984) pointed out the need to discriminate implementation outcomes from effectiveness outcomes in single-case and group design studies. In the two decades that followed, Fixsen, Blase, and others argued that only when effective practices and programs are fully implemented should we expect positive outcomes (Bernfeld, 2001; Fixsen & Blase, 1993; Institute of Medicine- Committee on Quality of Health Care in America, 2001; Washington State Institute for Public Policy, 2002; cited in Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). Discussion of treatment fidelity has become more frequent in the last decade, fueled by changing standards for methodological rigor in educational research and public concern for implementing evidence-based practices in school and community settings (e.g., Borrelli, 2011; Elliott & Mihalic, 2004; Kratochwill & Stoiber, 2002; Stockard, 2010).The current issue provides representative sample of where the field of ECSE stands in the evolving consideration of implementation fidelity. These six articles link emergent conceptual frameworks in treatment implementation fidelity to the training and coaching process used for professional development (PD) in ECSE and to measuring fidelity of interventions in literacy, behavior disorders, social emotional support, and family interventions. Two articles report specifically on the progress toward reporting implementation fidelity in the field of ECSE.Dunst, Trivette, and Raab (p. 85) introduce an implementation science framework and provide specifications for measuring fidelity in ECSE research. In introducing this framework, they propose the use of the term implementation to refer to a specific set of [professional development] activities designed to put into practice an [intervention] activity. They argue that the use of any type of early childhood intervention practice requires attention to not only the fidelity of the intervention practice but also the fidelity of the methods used to promote the use of that practice. They also point out the need for understanding the active ingredients of implementation practices and interventions. Essentially, measurement of fidelity should index the active ingredients of implementation and intervention; further, the determination of active ingredients should be linked to research-based evidence of effectiveness. Dunst et al. provide conceptual model and analytical framework for linking variations in implementation fidelity, variations in the intervention as delivered, and practice outcomes for children and families. They illustrate the application of this model using data from Head Start research project in which teachers were taught to implement early literacy practices.Powell and Diamond's (p. 102) argument for the application of implementation science principles in examining PD in experimental studies of language and literacy instruction for preschoolers follows the logic offered by Dunst et al. Powell and Diamond propose that critical link in the PD pathway, the individualized coaching provided to teachers as means of training them to use new intervention procedure, is largely black box. They use their conceptual framework for coaching (Powell & Diamond, 2013) that emphasizes structure, content, and process to describe the impact of coaching on teachers' implementation of evidence-based literacy practices. The procedures for coaching were derived from series of iterative experimental PD studies. In this issue, they report data from hybrid coaching-based PD program offered to Head Start teachers. …

Self-regulation prompts can increase fruit consumption: A one-hour randomised controlled online trial

Objective : The purpose was to examine whether a 1-h intervention would help increase fruit consumption in motivated individuals and to study the role of self-regulatory mechanisms in the behaviour change process, with a particular focus on dietary planning and action control. Methods : A randomised controlled trial compared a 1-h online intervention with controls in 791 participants. Dependent variables were fruit intake, planning to consume and dietary action control. Results : Experimental condition by time interactions documented superior treatment effects for the self-regulation group, although all participants benefited from the study. To identify the contribution of the intervention ingredients, multiple mediation analyses were conducted that yielded mediator effects for dietary action control and planning. Conclusions : A very brief self-regulatory nutrition intervention was superior to a control condition. Dietary planning and action control seem to play a major role in the mechanisms that facilitate fruit intake.

Integrating brain and behavior: Evaluating adolescents’ response to a cannabis intervention.

Client language (change talk [CT] and counterchange talk [CCT]) is gaining increasing support as an active ingredient of psychosocial interventions. Preliminary work with adults suggests that there may be a neural basis for this. With a diverse sample of adolescent cannabis users, we evaluated the influence of CT and CCT on blood oxygen level dependent (BOLD) response during an fMRI cannabis cue-exposure paradigm. We also investigated how BOLD activation related to treatment outcomes. Adolescent cannabis users (N = 43; 83.7% male; 53.5% Hispanic; M age = 16 years) were presented with CT and CCT derived from their prescan intervention session during the fMRI paradigm. Additionally, BOLD activation during CT (vs. CCT) was tested as a predictor of 1-month follow-up cannabis use behavior (frequency of cannabis use, cannabis problems, cannabis dependence). We observed a significant interaction, with greater activation during CT (vs. CCT) during the cannabis (but not control) cues in several areas key to self-referential processes (uncorrected p < 0.001; medial frontal gyrus, insula). Furthermore, BOLD activation during CT (vs. CCT) during cannabis (but not control) cues in areas that underlie introspection (posterior cingulate, precuneus) was significantly related to youths' 1-month follow-up cannabis use behavior (frequency of cannabis use, cannabis problems, cannabis dependence; uncorrected p < 0.001). These data indicate a unique interaction pattern, whereby CT (vs. CCT) during the cannabis (but not control) cues was associated with significantly greater activation in brain areas involved in introspection. Further, this activation was related to significantly better treatment outcomes for youth.

Appreciative clinical training.

This article presents a training model that has been used for 4 years in a graduate program in clinical psychology. The specific goal of the training model is to encourage beginning supervisors to identify their character strengths, refocus their attention and memory on the origin of these strengths, and cultivate their character strengths in the service of the supervision relationship. The most common character strengths of a group of clinical psychology graduate students are explored and compared with the general population, because an understanding of the strengths of your students has implications for education and training. Qualitative data are also presented that reveals the following themes: the power of focusing on one's strengths, the value of a strength-based approach, the complexity of strength-based work, and the notion of strengths born from challenge. The purpose of this article is to present a model of supervision training that enhances effective supervision and encourages the use of character strengths in the service of the supervision relationship. Appreciative clinical training values affirm and highlight strengths in supervision relationships. The intention of appreciative clinical training is to facilitate the cultivation of strengths through a refo- cusing of attention and memory using assessment, reflective dia- logue, and appreciative inquiry. Refocusing of attention and mem- ory are key ingredients of positive interventions (Rashid, 2009), and in this model the shift is from a deficit-based to a strength- based focus of clinical inquiry or intervention. Appreciative clinical training is informed by the principles of Appreciate Inquiry (AI) (Cooperrider & Srivastva, 2000; Cooper- rider & Whitney, 1999; Whitney & Trosten-Bloom, 2010), insofar as it is an inquiry into supervision at its best, and suggests that if you want to transform a situation or a relationship, focusing on strengths is often more effective than focusing on problems. Ap- preciative clinical training questions what you want more of in your supervision relationships and assumes that you will move in the direction of the questions you ask. We use strength-based questions as the focus of our inquiry—for example, When therapy or supervision is going really well, which of your strengths shine through? What creates nourishing, connected, and focused therapy and supervision relationships? What facilitates independence and self-sufficiency in your clinical relationship?—in contrast to a deficit-based focus of clinical inquiry, for example, What is the problem you are having with your client? Where are you stuck? Can you tell me what is giving you the most trouble in this case? Strength-based approaches to supervision are a growing part of the field of clinical training. Falender and Shafranske (2004) note that one half of a professional psychologist's formal training comes in the form of supervision and propose a competency-based approach to enhance the skills of the supervisor and supervisee. Empirical evidence suggests that the use of strengths helps make progress toward goals and increases relationship proficiency (Lin- ley, Nielsen, Gillett, & Biswas-Diener, 2010), both of which are core competencies in the supervision relationship. In a study of law school students, Peterson and Peterson (2009) found that the use of one's top strengths leads to a decrease in depression and an increase in work-related satisfaction. Sheldon and Lyubomirsky (2006) found that visualizing one's best possible self leads to an

Interventions Addressing Social Impairment in Autism

Children with an autism spectrum disorder have significant impairment in social skills. This area of development has also been the focus of many intervention studies. In this article we review intervention studies published over the past two years. Three topical areas were addressed in current interventions: social skills knowledge, peer relationships, and joint attention/joint engagement. Younger children most often received interventions on joint attention/joint engagement and older, higher functioning children received interventions on social knowledge and peer relationship development. Both single subject research designs and group designs were reviewed. One advancement was that more randomized controlled trials were reported, as well as effectiveness trials in the community. Study quality was also rated. More group than single subject designs were rated as adequate or strong in quality. Overall, moderate to large effects were found for interventions targeting joint attention/joint engagement and peer relationships with mixed effects on interventions targeting social skills knowledge. Future studies should focus on isolating the active ingredients of interventions and include broader participant representation.

Optimal intervention intensity in speech-language pathology: Discoveries, challenges, and unchartered territories

This article is the final response in a scientific forum on the optimal intensity of intervention in speech-language pathology. It is a reflection on the state of knowledge offered by the 13 commentaries in this issue, addressing the areas of early communication and language impairment, speech sound disorders in children, emergent literacy, reading, aphasia, dysphagia, stuttering, motor speech disorders, voice disorders, and traumatic brain injury. Although more intense intervention can lead to better outcomes, the relationship between intensity and outcome is not always linear. More is not always better. Non-intense and intense schedules can yield similar outcomes. Intensity can also reach a point of diminishing return. The insights offered by the authors illustrate the challenges involved in studying this complex issue. To establish the optimal intensity of interventions in speech-language pathology our field needs to: identify active ingredients of interventions; better understand how principles of motor learning and neural plasticity facilitate learning; appreciate the contribution of individuals characteristics, values, and preferences; discover the effect of specific combinations of intensity (including dose, dose form, dose frequency, session duration, and total intervention duration) on treatment outcomes, and find practical solutions when disparities exist between research recommendations and workplace limitations.