Single-case Multiple-baseline Design Research Articles

The impact of a hospital-based special care unit on behavioural and psychological symptoms in older people living with dementia.

Hospital patients with behavioural and psychological symptoms of dementia (BPSD) are vulnerable to a range of adverse outcomes. Hospital-based Special Care Units (SCUs) are secure dementia-enabling environments providing specialised gerontological care. Due to a scarcity of research, their value remains unconfirmed. To compare hospital based SCU management of BPSD with standard care. Single-case multiple baseline design. One-hundred admissions to an 8-bed SCU over 2 years in a large Australian public hospital. Repeated measures of BPSD severity were undertaken prospectively by specialist dementia nurses for patients admitted to a general ward (standard care) and transferred to the SCU. Demographic and other clinical data, including diagnoses, medication use, and care-related outcomes were obtained from medical records retrospectively. Analysis used multilevel models to regress BPSD scores onto care-setting outcomes, adjusting for time and other factors. When receiving standard care, patients' BPSD severity was 6.8 (95% CI 6.04-7.64) points higher for aggression, 15.6 (95% CI 13.90-17.42) points higher for the neuropsychiatric inventory, and 5.8 (95% CI 5.14-6.50) points higher for non-aggressive agitation compared to SCU. Patients receiving standard care also experienced increased odds for patient-to-nurse violence (OR 2.61, 95% CI 1.67-4.09), security callouts (OR 5.39 95% CI 3.40-8.52), physical restraint (OR 17.20, 95% CI 7.94-37.25) and antipsychotic administration (OR 3.41, 95% CI 1.60-7.24). Clinically significant reductions in BPSD and psychotropic administration were associated with SCU care relative to standard ward care. These results suggest more robust investigation of hospital SCUs, and dementia-enabling design are warranted.

Riding waves to improve functioning: a quantitative evaluation of a Surf Week in individuals with chronic phase brain injury with six months follow-up

Purpose Environmental enrichment seems to enable people in the chronic phase of acquired brain injury (ABI) to experience new functional abilities and motor/coping strategies and consequently to become more adaptable which might prevent/reverse functional decline. This study describes the influence of a five-days Surf Week program on participants on physical function, self-efficacy, functional balance performance and self-perceived recovery. Materials and methods A multiple-baseline single-case design was used. Adults participating in the Surf Week in chronic phase of ABI were eligible to participate. Participants completed a battery of tests monitoring physical function, self-efficacy, functional balance performance and self-perceived recovery. This battery was repeated 5 times over a 1-year period, two times pre-Surf Week, three times post-Surf Week. Visual data inspection with two non-overlap methods were used to determine if patients showed sustained improvement in outcomes post-intervention. Results A moderate to strong indication for improvements on physical function, functional balance performance and self-perceived recovery exists till six months follow-up. No indication was observed on self-efficacy till six months follow-up. Conclusions A five-days Surf Week is a physically, cognitively and socially intensive stimulating activity that can positively challenge individuals after ABI and seems to improve physical functioning, functional balance performance and self-perceived recovery.

Efficacy of an Intensive Exposure Intervention for Individuals With Persistent Concussion Symptoms Following Concussion: A Concurrent Multiple Baseline Single-Case Experimental Design (SCED) Study.

After a concussion, 1 in 3 patients report persistent symptoms and experience long-term consequences interfering with daily functioning, known as persistent concussion symptoms (PCS). Evidence suggests PCS is (partly) maintained by anxious thoughts about brain functioning, recovery, and experienced symptoms, leading to avoidance behaviors, which may prevent patients from meeting life demands. We aimed to investigate the efficacy of a newly developed intensive exposure intervention for individuals with PCS after concussion aimed to tackle avoidance behavior. Participants took part in the intervention at the Maastricht University faculty. Four participants who experienced PCS after concussion partook in the exploratory study. Participants' age ranged between 20 and 32 (mean = 26.5, SD = 5.9) years, with an average length of time after the concussion of 9.8 months. A concurrent multiple-baseline single-case design was conducted. The baseline period (A phase) length was randomly determined across participants (3, 4, 5, or 6 weeks). The exposure intervention (B phase) was conducted by psychologists over a 4-week period and consisted of 3 stages: exploration (2 sessions), active exposure (12 sessions conducted over 1 week), and 2 booster sessions. Participants answered daily questions on a visual analog scale related to symptom experience, satisfaction with daily functioning, and degree of avoidance of feared activities. Additional outcomes included symptom severity, catastrophizing, fear of mental activity, anxiety, depression, and societal participation. Tau-U yielded significant effects (P < .05) for all participants on all measures when comparing baseline and intervention phases. The pooled standardized mean difference was high for all measures (symptom experience = 0.93, satisfaction of daily functioning = 1.86, and activity avoidance = -2.05). The results show efficacy of the newly developed intensive exposure treatment for PCS after concussion, which is based on the fear avoidance model. Replication in a larger heterogeneous sample is warranted and needed.

Effectiveness of Day Treatment Group Schema Therapy for Personality Disorders: A Multiple Baseline Single-Case Study.

Schema therapy is effective for most outpatients with personality disorders (PDs). However, a subgroup does not sufficiently benefit from outpatient programmes. Despite its common clinical use, a thorough evaluation of day treatment group schema therapy (GST) is lacking. This study aimed to investigate the effectiveness of day treatment GST for patients with PDs. Negative core beliefs were the primary outcome in a multiple baseline single-case design, measured weekly before and during 30 weeks of day treatment GST. Secondary outcomes included severity of primary PD, early maladaptive schemas (EMS), schema modes and general psychopathology measured before and after day treatment GST. Intervention effects were evaluated through visual inspection and randomization test analysis, with a reliable change index calculated for the secondary outcome measures. A total of 79% of treatment completers showed a significant positive effect of day treatment GST with large effect sizes (Cohen's d: 0.96-10.04). Secondary outcomes supported these findings: 56% had a significant decrease in the severity of primary PD and 53% in general psychopathology. In addition, 63% of EMS and 72% of schema modes (87.5% for functional schema modes) showed significant positive reliable changes. This is the first empirical study that demonstrated the effectiveness of day treatment GST in patients with severe PDs. Day treatment GST can serve as a stepped care treatment option for nonresponsive patients in outpatient programmes. Further randomized controlled (cost-)effectiveness research is necessary to substantiate these findings and investigate the specific patient populations for which day treatment is essential.

The Lighter Touch: Less-Restriction in Sequentially Implemented Behavioral Sleep Interventions for Children with Rare Genetic Neurodevelopmental Conditions.

The prevalence of sleep difficulties among children with rare genetic neurodevelopmental conditions (RGNC) is high. Behavioral interventions are commonly used in the treatment of sleep difficulties in children with neurodevelopmental conditions such as autism, however, research is scarce in children with RGNC. The range of co-occurring complexities within this population, means there is a need for research to not only determine the effectiveness of behavioral sleep interventions, but also which components might be the least restrictive (i.e., intensive/aversive) and minimally sufficient. This study used a single-case multiple baseline design to investigate the effectiveness and acceptability of behavioral sleep interventions, indicated within a Functional Behavior formulation in eight children with RGNC (M = 7.3years). Intervention components were sequentially administered across up to three phases, based on the principle of less restriction (from least to relatively more intensive) to determine what might be minimally sufficient. Results showed an improvement in sleep onset latency, night wakings, early morning waking and unwanted bed-sharing for 7/7, 6/7, 3/3 and 3/3 children respectively. Improvement was observed for most participants following the less restrictive phases of intervention (circadian modifications, antecedent modifications and positive reinforcement), however, more restrictive, albeit modified, extinction procedures were still implemented for five participants. Improvements were maintained at follow-up and interventions were deemed acceptable to parents. Less restrictive function-based behavioral strategies are an effective, and in some cases sufficient, contribution to a sequence of interventions for a range of sleep difficulties. They should be implemented first, before more restrictive strategies.

Integrated Behavior Therapy for Exclusively Anxious Selective Mutism: A Nonconcurrent Multiple-Baseline Design across Five Participants.

Selective mutism (SM) is a rare childhood anxiety disorder which may be markedly detrimental to a child's academic and social functioning if left untreated. Cognitive-behavioral treatments for social anxiety disorders have been found to be effective for SM, yet a paucity of published studies have explored manualized treatment approaches carried out by novice clinicians. The purpose of the present study was to examine the adherence, effectiveness, and acceptability of a condensed, 16-session version of Integrated Behavior Therapy for Selective Mutism (IBTSM; Bergman, 2013), the first manualized treatment for SM. A nonconcurrent multiple-baseline single-case design was used across five children diagnosed with SM, exclusively anxious subtype. IBTSM was implemented with excellent adherence (M = 98%) over an average of 19 weeks (range = 16-22 weeks). Visual analyses of weekly caregiver ratings of social anxiety and speaking behaviors did not demonstrate a replicated intervention effect; however, Tau-U effect sizes and Reliable Change Index (RCI) calculations demonstrated significant individual improvements in social anxiety and speaking behaviors over time on several measures. Three children (60%) no longer met diagnostic criteria for SM following treatment. All caregivers rated IBTSM as acceptable, with specific endorsements of acceptability in the areas of time required and treatment quality.

Teaching Receptive Vocabulary to Minimally Verbal Preschoolers With Autism Spectrum Disorder: A Single-Case Multiple Baseline Design.

The purpose of this multiple probe design was (a) to investigate whether the use of the match-to-sample (MtS) procedure would result in independent identification of objects and (b) to examine whether the participants could generalize to matching objects and nonidentical pictures. Using a nonconcurrent multiple baseline design, three minimally verbal preschoolers with autism spectrum disorder and receptive language impairment were taught to identify common objects using a MtS procedure and physical prompts. Participants were taught to match identical objects to identical pictures. Maintenance checks were completed following mastery of vocabulary for a total of 22 words. Generalization probes were conducted with the objects and nonidentical pictures. Intervention was completed by a speech-language pathologist during typical speech-language pathology sessions. Results illustrated that all of the participants learned to match and generalize the pictures. All were able to independently identify the objects at 1-month follow-up. MtS and prompting appear to be effective procedures for teaching receptive vocabulary and can be easily implemented by education professionals. Learner profiles varied for the participants in this study and are an important aspect when teaching students with autism spectrum disorder and co-occurring receptive language impairment.

Supporting Autistic Adults’ Social Skill Development Using Video Modeling in a Community-Based Program

Autistic individuals have significant social-communication challenges that commonly persist into adulthood and impact academic, social, and vocational pursuits. More than two decades of research have established video behavior modeling as a successful, cost-effective, and time efficient intervention tool for autistic children; however, less research has investigated the use of video modeling with autistic adults, and only a handful of studies have assessed its effects in non-vocational community-based settings. This study examines the effects of video modeling on social-communication skills of autistic adults in a community-based fitness group using a multiple-baseline single-case design with replication across participants. Additional data on visual attention, generalization, and social validity were captured. Results show variable effects across participants and provide valuable information to guide individuals in choosing effective and practical evidence-based practices to support the social-communication success of autistic adults.

Teaching argument writing in math class: challenges and solutions to improve the performance of 4th and 5th graders with disabilities.

Incorporating argument writing as a learning activity has been found to increase students' mathematics performance. However, teachers report receiving little to no preservice or inservice preparation to use writing to support students' learning. This is especially concerning for special education teachers who provide highly specialized mathematics instruction (i.e., Tier 3) to students with mathematics disabilities (MLD). The purpose of this study was to examine the effectiveness of teachers providing content-focused open-ended questioning strategies, which included both argument writing and foundational fraction content, using Practice-Based Professional Development (PBPD) and Self-Regulated Strategy Development (SRSD) for implementing a writing-to-learn strategy called FACT-R2C2. We report the relative number of higher-order mathematical content questions that teachers asked during instruction, from among three different-level question types: Level 1: yes/no questions focused on the mathematics content; Level 2: one-word responses focused on the mathematics content; and Level 3: higher-order open-ended responses centered around four mathematical practices from the Common Core State Standards for Mathematics. Within a well-controlled single-case multiple-baseline design, seven special education teachers were randomly assigned to each PBPD + FACT-R2C2 intervention tier. Results indicated that: (1) teachers' relative use of Level 3 questions increased following the introduction of the FACT intervention; (2) this increase was apart from the professional development training that the teachers had initially received; and (3) students' writing quality improved to some extent with the increase in teachers' relative use of Level 3 questions. Implications and future directions are discussed.

Improving Expository Text Comprehension in Adolescent Spanish–English Bilingual Learners With Learning Disabilities Using a Graphic Organizer

The purpose of this study was to examine the efficacy of a graphic organizer for improving the expository text comprehension of adolescent Spanish–English bilingual students with learning disabilities. Students included two females and one male. Using a multiple baseline single case design, students were taught to create a funnel map graphic organizer for 10 descriptive text passages. Students’ performance was assessed on their ability to correctly create the funnel map (criterion variable) and to comprehend expository passages during baseline, intervention, and maintenance phases. Each participant learned to create an accurate funnel map within four sessions. Text comprehension scores began to increase within three sessions. Results showed the positive effect of using the funnel map for improving comprehension of expository texts. Individual TAU effect sizes (.81–.92) and overall TAU-U effect sizes (.86) and a Between Case-Standardized Mean Difference (BC-SMD) of 1.87 showed the intervention to be highly effective.

How Does Meditation-Based Lifestyle Modification Affect Pain Intensity, Pain Self-Efficacy, and Quality of Life in Chronic Pain Patients? An Experimental Single-Case Study.

Chronic pain is a growing worldwide health problem and complementary and integrative therapy options are becoming increasingly important. Multi-component yoga interventions represent such an integrative therapy approach with a promising body of evidence. The present study employed an experimental single-case multiple-baseline design. It investigated the effects of an 8-week yoga-based mind-body intervention, Meditation-Based Lifestyle Modification (MBLM), in the treatment of chronic pain. The main outcomes were pain intensity (BPI-sf), quality of life (WHO-5), and pain self-efficacy (PSEQ). Twenty-two patients with chronic pain (back pain, fibromyalgia, or migraines) participated in the study and 17 women completed the intervention. MBLM proved to be an effective intervention for a large proportion of the participants. The largest effects were found for pain self-efficacy (TAU-U = 0.35), followed by average pain intensity (TAU-U = 0.21), quality of life (TAU-U = 0.23), and most severe pain (TAU-U = 0.14). However, the participants varied in their responses to the treatment. The present results point to relevant clinical effects of MBLM for the multifactorial conditions of chronic pain. Future controlled clinical studies should investigate its usefulness and safety with larger samples. The ethical and philosophical aspects of yoga should be further explored to verify their therapeutic utility.

The Effects of Virtual Caregiver Coaching in Antigua & Barbuda on the Implementation of EMT Language Support Strategies in Naturalistic Environments.

This single-case multiple baseline design investigation set out to determine the effectiveness of using a telepractice service delivery model to coach caregivers in Antigua & Barbuda in the use of Enhanced Milieu Teaching (EMT) language support strategies with a child with language impairment. A slightly modified version of the Teach-Model-Coach-Review (TMCR) method was used during virtual instruction to train a caregiver on the language support strategies of environmental arrangement, matched turns, expansions, and time delay with milieu prompting. The caregiver attended sessions three times a week for up to 45 minutes for four weeks. The results of this study indicated a positive relationship between the intervention and caregiver use of strategies. The caregiver demonstrated increased responsiveness to the child's communication attempts and exhibited the use of language support strategies across activities. This study suggests that telepractice can be an effective service delivery model for providing coaching to caregivers.

Proof of concept and feasibility of a blended physiotherapy intervention for persons with haemophilic arthropathy.

Regular physiotherapy with a physiotherapist experienced in the field is not feasible for many patients with haemophilia. We, therefore, developed a blended physiotherapy intervention for persons with haemophilic arthropathy (HA) (e-Exercise HA), integrating face-to-face physiotherapy with a smartphone application. The aim of the study was to determine proof of concept of e- Exercise HA and to evaluate feasibility. Proof of concept was evaluated by a single-case multiple baseline design. Physical activity (PA) was measured with an accelerometer during a baseline, intervention and post-intervention phase and analysed using visual inspection and a single case randomisation test. Changes in limitations in activities (Haemophilia Activities List [HAL]) and a General Perceived Effect (GPE) were evaluated between baseline (T0), post-intervention (T1) and 3 months post-intervention (T2) using Wilcoxson signed rank test. Feasibility was evaluated by the number of adverse events, attended sessions and open-ended questions. Nine patients with HA (90% severe, median age 57.5 (quartiles 50.5-63.3) and median HJHS 32 (quartiles 22-36)) were included. PA increased in two patients. HAL increased mean 15 (SD 9) points (p=.001) at T1, and decrease to mean +8 points (SD 7) (p=.012) at T2 compared to T0. At T1 and T2 8/9 participants scored a GPE>3. Median 5 (range 4-7) face-to-face sessions were attended and a median 8 out of 12 information modules were viewed. No intervention-related bleeds were reported. A blended physiotherapy intervention is feasible for persons with HA and the first indication of the effectiveness of the intervention in decreasing limitations in activities was observed.

Less Restrictive Behavioral Interventions for Sleep Problems in Children with Neurodevelopmental Disorders: A Single Case Feasibility Study

Sleep problems are prevalent among autistic children and children with Rare Genetic Neurodevelopmental Disorders (RGND). Behavioral interventions are commonly used to treat sleep problems, with most involving extinction. While effective, the occurrence of a response burst (i.e., temporary worsening of the behavior) can result in a temporary increase in parent and child distress, and negatively affect treatment adherence. Thus, it is important to develop less restrictive treatment options. This study used a single case multiple baseline design to investigate the effectiveness and acceptability of less restrictive behavioral interventions (i.e., specifically excluding extinction) for sleep problems in ten autistic children and children with RGND (M = 7.3 years). Results demonstrated a reduction in sleep disturbance including unwanted bed-sharing, night wakings and sleep onset delay for 3/3, 5/5 and 6/7 children respectively, which were maintained at follow-up. Interventions were rated favorably by parents. The clinical implications of these findings are discussed.

Remote Delivery of Prevent Teach Reinforce for Families

A single-case multiple baseline design across three families was used to evaluate the impact of a manualized Prevent Teach Reinforce for Families (PTR-F) process for addressing challenging behavior (CB) when delivered in a remote format (PTR-F: R). Results across three families showed that (a) a functional relation existed between parent implementation of the strategies and reductions in child’s CB, (b) families achieved high levels of implementation fidelity for behavior intervention plans developed using the PTR-F: R process, and (c) families rated the PTR-F: R process and the intervention plans positively. The results replicated findings from previous research on the general efficacy of the PTR process while adapting the method for use in a remote format. Implications for practice and future research are discussed.

Response inhibition training for compulsive acquisition in hoarding: A multiple baseline single case design

• Past research suggests Response Inhibition Training is effective in reducing impulsive behaviour. • This study examined if RIT could effectively reduce acquisition in Hoarding. • 8 participants were involved in a single case experimental design. • No significant difference was seen on measures of hoarding following RIT. • Participants reported an increased awareness of acquisition and saving post- RIT.

Creating Compassion: Creatively-Focused Explicit Behavioral Instruction for Empathy Development

Creating Compassion is an empathy-focused creative arts curriculum designed to provide short-term, low-cost, high-quality social–emotional learning (SEL) to communities and settings with limited resources. The present study sought to determine whether Creating Compassion was effective for increasing displays of prosocial behaviors and broad SEL skills for early elementary school students (n = 9) through a multiple baseline single-case design, as empathy has previously been posited as a core factor in global social–emotional skill development. Results from this study confirmed the hypothesis that Creating Compassion would increase observed prosocial behaviors with moderate effectiveness for children in first, second, and third grades, including those with identified social–emotional skill deficits. Participant scores on a pre/post assessment of global SEL competence also increased after intervention. Ultimately, findings from this study suggest the Creating Compassion intervention might be used by school psychologists and other group interventionists to expose their school communities to arts programming and engage them in a fun and creative approach to accessible early SEL intervention. Impact Statement This paper presents results from a combined arts and empathy training intervention, Creating Compassion. As an empathy-focused intervention, implementation of Creating Compassion led to increases in displays of prosocial behavior with moderate effectiveness. Increases in participants’ levels of overall SEL skill competence were also observed. Results from this study support the provision of a high-quality, low-cost, arts-based SEL program to benefit Low-Income and Economically Marginalized (LIEM) communities within educational settings.

Evaluating a Novel Treatment Adapting a Cognitive Behaviour Therapy Approach for Sexuality Problems after Traumatic Brain Injury: A Single Case Design with Nonconcurrent Multiple Baselines.

There has been little progress in development of evidence-based interventions to improve sexuality outcomes for individuals with traumatic brain injury (TBI). This study aimed to evaluate the preliminary efficacy of an individualised intervention using a cognitive behaviour therapy (CBT) framework to treat sexuality problems after TBI. A nonconcurrent multiple baseline single-case design with 8-week follow-up and randomisation to multiple baseline lengths (3, 4, or 6 weeks) was repeated across nine participants (five female) with complicated mild–severe TBI (mean age = 46.44 years (SD = 12.67), mean post-traumatic amnesia = 29.14 days (SD = 29.76), mean time post-injury = 6.56 years (median = 2.50 years, SD = 10.11)). Treatment comprised eight weekly, individual sessions, combining behavioural, cognitive, and educational strategies to address diverse sexuality problems. Clinical psychologists adopted a flexible, patient-centred, and goal-orientated approach whilst following a treatment guide and accommodating TBI-related impairments. Target behaviour was subjective ratings of satisfaction with sexuality, measured three times weekly. Secondary outcomes included measures of sexuality, mood, self-esteem, and participation. Goal attainment scaling (GAS) was used to measure personally meaningful goals. Preliminary support was shown for intervention effectiveness, with most cases demonstrating sustained improvements in subjective sexuality satisfaction and GAS goal attainment. Based on the current findings, larger clinical trials are warranted.

Is ACT-Informed Exposure a Viable Treatment for Excoriation Disorder? A Multiple Baseline Study.

This study piloted the use of ACT-informed exposure as an adjunct to habit reversal training (HRT) for excoriation disorder (ExD). Using a nonconcurrent multiple baseline single case design, four participants completed sessions of exposure and HRT. Repeated measures and self-report data were collected on skin picking and psychological flexibility. Two participants completed HRT followed by exposure, and two participants completed exposure followed by HRT. Results support the effectiveness of HRT in reducing picking. Results suggest exposure may have some impact in reducing picking, but effects were weaker compared to HRT. Contrary to predictions, repeated measures and self-report data did not indicate consistent improvement in psychological flexibility during exposure phases. As any reduction in picking may be clinically meaningful and all participants maintained gains at follow-up, there is some indication that exposure may be a second-line treatment worth further study. Limitations and future areas of research are discussed.

A Module-Based Telepractice Intervention for Parents of Children with Developmental Disabilities.

In the current study, we describe a study of the Internet-based Parent-implemented Communication Strategies-Storybook (i-PiCSS). I-PiCSS is an intervention program designed to train and coach parents to use evidence-based naturalistic communication teaching (NCT) strategies (i.e., modeling, mand-model, and time delay) and reading techniques while reading storybooks with their young children with disabilities. Three participating parents were trained via online modules and coached via telepractice technologies (videoconferences). Zoom videoconference software was used for all coaching sessions. Using a single case multiple-baseline design across NCT strategies within each family, we examined, (a) parents' fidelity use of the three NCT strategies, (b) parents' use of book reading techniques, and (c) child language and communication outcomes. After self-directed training and remote coaching, parents used modeling, mand-model, and time delay strategies with higher rates and fidelity (accuracy). Children initiated more communicative acts upon parents' use of time delay and increased their numbers of single-and multiple-word responses.