Non-concurrent Multiple Baseline Design Research Articles

Concurrence on Nonconcurrence in Multiple-Baseline Designs: A Commentary on Slocum et al. (2022).

Slocum et al. (this issue) provide well-reasoned arguments for the use of nonconcurrent multiple baseline designs in behavior analytic work, despite historical preference for concurrent designs (i.e., simultaneous baseline initiation) and contemporary guidelines in related fields suggesting that nonconcurrent designs are insufficient for evaluating functional relations (What Works Clearinghouse, 2020). I provide a commentary, highlighting major contributions of this article and suggesting areas of further consideration. In sum, I agree with authors that researchers should avoid wholesale dismissal of nonconcurrent designs. I also agree that understanding how multiple-baseline designs control for and allow for detection of threats to internal validity is critical so that authors can apply the variation of the design that allows them to draw confident conclusions about relations between independent and dependent variables.

Examining and Enhancing the Methodological Quality of Nonconcurrent Multiple-Baseline Designs.

In this article we respond to the recent recommendation of Slocum et al. (2022), who provided conceptual and methodological recommendations for reconsidering the credibility and validity of the nonconcurrent multiple-baseline design. We build on these recommendations and offer replication and randomization upgrades that should further improve the status of the nonconcurrent version of the design in standards and single-case design research. Although we suggest that the nonconcurrent version should be an acceptable methodological option for single-case design researchers, the traditional concurrent multiple-baseline design should generally be the design of choice.

Maximizing the non-specific factors in brief cognitive behavioral therapy for panic disorder and agoraphobia: A multiple baseline case series documenting feasibility and initial efficacy.

There is evidence for non-specific factors impacting treatment outcomes, with pragmatic concerns regarding the need to popularize briefer formats of cognitive behavioral therapy (CBT). The need to have more culturally suitable and acceptable forms of CBT is also indicated. We evaluated the feasibility and efficacy of a brief 5 session CBT (bCBT) in participants (N = 4) with panic disorder (PD) and agoraphobia, using a non-concurrent multiple baseline design. In this case series, efforts were made to maximize non-specific factors of psychotherapy in bringing about treatment outcomes. Reliable and significant treatment effects were observed at post-intervention and follow-up assessments. The present study offers preliminary evidence of a bCBT protocol that comprises the efforts to maximize the non-specific factors in psychotherapy such as credibility, expectancy, and the therapeutic alliance in bringing treatment outcomes; however, further controlled evaluation is warranted. We also discuss the mechanisms contributing to these treatment outcomes in the present protocol.

The Effectiveness of Acceptance and Commitment Therapy (ACT) on Anxiety and Self-efficacy of Children: A Single-Case Experimental Design

Aim: The aim of the current study was to investigate the effectiveness of Acceptance and Commitment Therapy (ACT) on Anxiety and Self-efficacy of children among children with anxiety. Methods: The statistical population consisted of all children diagnose with anxiety in Ahvaz. The research sample consisted of 3 children that were selected according to the results of the Child Anxiety Related Emotional Disorders (SCARED) , using purposeful sampling method. In this research, a single-case experimental design, type of non-concurrent multiple baseline designs was used. To evaluate the anxiety, Child Anxiety Related Emotional Disorders (SCARED) and self-Efficacy - Children's Self-Efficacy Scale were used. The data was collected in three phases of baseline, during intervention, and one month follow-up. Findings: The findings indicate that the subjects in the treatment phase experienced improvement in anxiety (30/96) and self-efficacy (28/13), and in the follow-up in regards to anxiety (38/44) and self-efficacy (32/25). The change index was indicative of meaningful changes (z=1/95 α=0.05). Conclusion: Therefore, the research findings illustrated that Acceptance and Commitment Therapy reduces anxiety and increases children's self-efficacy by increasing psychological flexibility and reducing dysfunctional reactions.

The Use of iPad and eBooks to Perform Daily Living Skills Among Adolescents With Autism Spectrum Disorder and Intellectual Disability

In the current study, three adolescents with autism spectrum disorder and moderate intellectual disability were first taught to independently use an iPad to access instructional material (i.e., video models) via electronic books or eBooks. After iPad training, participants were required to apply their newly acquired skills to independently operate the iPad and eBooks to learn and perform other novel daily living tasks. The study employed a single case, non-concurrent multiple baseline design across participants during the iPad training phase and across tasks for each participant during the application phase. Results based on visual analysis indicated that all participants learned to independently operate the iPad and access instructional materials presented via eBooks. Furthermore, they applied these skills to learn and independently perform other novel daily living tasks. Effect size estimates using between case standardized mean difference showed improvements in responding subsequent to iPad training.

What is the effect of personalized cognitive strategy instruction on facilitating return-to-learn for individuals experiencing prolonged concussion symptoms?

ABSTRACT The purpose of this study was to evaluate the degree to which personalized cognitive strategy instruction (PCSI) assisted students with prolonged concussion symptoms (PCS) to achieve functional and academic-related goals. It was hypothesized that goal attainment on collaboratively developed functional goals and selected scores on the pre/post outcome measurements would improve following the delivery of PCSI. A non-concurrent multiple baseline design was utilized across three female participants ages 13–16. The weekly status tracking measurement of participant performance served as the primary measurement analysed to determine the existence of a functional relation between the addition of PCSI to psychoeducation and the achievement of participant outcome. Although visual analysis of the plotted status tracking data did not support the existence of a functional relation, all three participants met or exceeded functional goals on their goal attainment scales. A Tau-U analysis supported a small treatment effect. The positive response to the intervention from two of the three participants in addition to goal attainment for all three participants suggests PCSI has potential to mitigate cognitive challenges in adolescents with PCS. Implications for future research and methods to promote ecological measurement of intervention effects are discussed.

Bibliotherapy for Specific Phobias of Dogs in Young Children: A Pilot Study.

Bibliotherapy, particularly when supplemented with therapist contact, has emerged as an effective treatment for anxiety symptoms in children. However, its effectiveness in treating specific phobias in young children has been explored in only one study which targeted nighttime fears. The current study tested a novel bibliotherapy for fears of dogs in four to seven-year-old children. The therapy was conducted over four weeks and was supplemented with brief, weekly videoconference calls with a therapist. A non-concurrent multiple baseline design was used to evaluate the effectiveness of this treatment in a sample of seven children between four and seven years of age. Significant reductions in specific phobia diagnostic severity, parent and child fear ratings, and child avoidance during a behavioral approach task were all observed. Additionally, treatment adherence, retention, and satisfaction were all high. Future research is needed to replicate the findings in larger, more heterogeneous samples and to explore possible predictive variables; however, this study provides initial support for bibliotherapy as a non-intensive, first-line intervention for specific phobias in young children.

Linking process to outcome in Functional Analytic Psychotherapy: Evaluating the behavioral mechanism of change of a process-based therapy

Process-based therapy has received attention in recent years and seeks to advance our understanding of mechanisms of change in behavioral health interventions. A process-to-outcome research approach was employed to examine the mechanism of change and treatment effects of Functional Analytic Psychotherapy (FAP). A non-concurrent multiple baseline design was conducted with three clients who endorsed psychological distress and interpersonal difficulties. FAP's mechanism of change was tested with a lag sequential analysis. Statistical analysis for single-case designs was performed to assess between and within-participant treatment outcomes. High contingent and consistent reinforcement were associated with clinical changes in treatment outcomes. Therapeutic relationship factors such as therapeutic alliance and therapeutic relationship intimacy did not show moderation effects on treatment variables. Limitations and recommendations for improving reliability are discussed. The relations of treatment outcomes and FAP implementation are summarized. Finally, we discuss the relevance of process-to-outcome research for improving clinical science.

Acceptance and commitment therapy for individuals with depressive and anxiety symptoms following acquired brain injury: A non-concurrent multiple baseline design across four cases

ABSTRACT Patients with acquired brain injury (ABI) often experience symptoms of anxiety and depression. Until now, evidence-based treatment is scarce. This study aimed to investigate the effectiveness of Acceptance and Commitment Therapy (ACT) for patients with ABI. To evaluate the effect of ACT for people with ABI, a non-concurrent multiple baseline design across four cases was used. Participants were randomly assigned to a baseline period, followed by treatment and then follow-up phases. Anxiety and depressive symptoms were repeatedly measured. During six measurement moments over a year, participants filled in questionnaires measuring anxiety, depression, stress, participation, quality of life, and ACT-related processes. Randomization tests and NAP scores were used to calculate the level of change across phases. Clinically significant change was defined with the Reliable Change Index. Three out of four participants showed medium to large decreases in anxiety and depressive symptoms (NAP = 0.85 till 0.99). Furthermore, participants showed improvements regarding stress, cognitive fusion, and quality of life. There were no improvements regarding psychological flexibility, value-driven behaviour, or social participation. This study shows that ACT is possibly an effective treatment option for people experiencing ABI-related anxiety and depression symptoms. Replication with single case or large scale group studies is needed to confirm these findings.

Behavioral skills training to teach college students to free‐pour standard servings of alcohol

AbstractCollege student members of Greek Letter Organizations (GLOs) report high levels of alcohol consumption, which is associated with adverse academic and health consequences. Those who report lower consumption also report counting their drinks, which requires the ability to identify and pour standard servings of alcohol, skills college students generally lack. Behavioral skills training (BST) has been used to teach students to pour standard servings of beer. However, little is known about whether BST is effective when used in a small‐group format or with other alcohol types, and whether skills generalize across time and novel cups. We used a nonconcurrent multiple baseline design to address these gaps. After receiving small group BST, all participants poured beer accurately, most poured accurately at follow‐up, and about half poured accurately into a novel cup. After receiving individual BST, participants' pours of liquor were variable and most required additional training.

The Super Clean-Up Game: Increasing Productivity and Prosocial Engagement Among Youth at a Residential Summer Camp

The Good Behavior Game (GBG) is a behavior intervention typically used in traditional classroom settings. This study tested the effectiveness of the Super Clean-Up Game, a modified version of the GBG, for youth with disabilities at a residential summer camp to increase productivity and strengthen the social skills of youth with disabilities. The Super Clean-Up Game was implemented at a residential summer camp for youth with social, emotional, and behavioral challenges, with four bunks of campers ( N = 24, 100% boys, ages 10–15 years old) using a randomized nonconcurrent multiple-baseline design. There was an increase in the percentage of chore completion and peer helping behavior between the baseline and intervention phases in all four bunks. Results provide preliminary evidence that the Super Clean-Up Game is an effective behavior intervention at a residential summer camp for youth with social, emotional, and behavioral challenges. Future studies may consider modifying the Super Clean-Up Game for use in other contexts, such as classrooms or group homes.

Threats to Internal Validity in Multiple-Baseline Design Variations

Multiple baseline designs—both concurrent and nonconcurrent—are the predominant experimental design in modern applied behavior analytic research and are increasingly employed in other disciplines. In the past, there was significant controversy regarding the relative rigor of concurrent and nonconcurrent multiple baseline designs. The consensus in recent textbooks and methodological papers is that nonconcurrent designs are less rigorous than concurrent designs because of their presumed limited ability to address the threat of coincidental events (i.e., history). This skepticism of nonconcurrent designs stems from an emphasis on the importance of across-tier comparisons and relatively low importance placed on replicated within-tier comparisons for addressing threats to internal validity and establishing experimental control. In this article, we argue that the primary reliance on across-tier comparisons and the resulting deprecation of nonconcurrent designs are not well-justified. In this article, we first define multiple baseline designs, describe common threats to internal validity, and delineate the two bases for controlling these threats. Second, we briefly summarize historical methodological writing and current textbook treatment of these designs. Third, we explore how concurrent and nonconcurrent multiple baselines address each of the main threats to internal validity. Finally, we make recommendations for more rigorous use, reporting, and evaluation of multiple baseline designs.

Video Feedback to Enhance Fidelity in Practice-Based Interventions for Young People, a Small-n Study

Competent delivery of interventions in child and youth social care is important, due to the direct effect on client outcomes. This is acknowledged in evidence-based interventions (EBI) when, post-training, continued support is available to ensure competent delivery of the intervention. In addition to EBI, practice-based interventions (PBI) are used in the Netherlands. The current paper discusses to what extent competent delivery of PBI can be influenced by introducing supervision for professionals. This study used a mixed-method design: (1) A small- n study consisting of six participants in a non-concurrent multiple baseline design (MBL). Professionals were asked to record conversations with clients during a baseline period (without supervision) and an intervention period (with supervision). Visual inspection, the non-overlap of all pairs (NAP), and the Combinatorial Inference Technique (CIT) scores were calculated. (2) Qualitative interviews with the six participants, two supervisors, and one lead supervisor focused on the feasibility of the supervision. Four of six professionals showed improvement in treatment fidelity or one of its sub-scales. Had all participants shown progress, this could have been interpreted as an indication that targeted support of professionals contributes to increasing treatment integrity. Interviews have shown that supervision increased the professionals’ enthusiasm, self-confidence, and awareness of working with the core components of the intervention. The study has shown that supervision can be created for PBI and that this stimulates professionals to work with the core components of the intervention. The heterogeneous findings on intervention fidelity can be the result of supervision being newly introduced.

An Initial Pilot Study Examining Child Social Skills, Caregiver Styles, and Family Functioning in the PEERS® for Preschoolers Program for Young Autistic Children and their Caregivers

BackgroundSocial impairments characteristic of autism spectrum disorder (ASD) are evident in early childhood and worsen as the child matures. Though many interventions for young children exist, few specifically target social skills and involve caregivers. AimsThis pilot study examined PEERS® for Preschoolers, focusing on temporal change in child social skills, caregiver style, and family functioning in the context of a caregiver-assisted social skills intervention. This extension of the PEERS® program builds on the success of the intervention for older children, presenting skills in a developmentally appropriate manner to young autistic children and their caregivers. Methods and proceduresThe present pilot study used a non-concurrent multiple baseline design to examine the above variables with 15 autistic children (Mage = 4.87, SD = 1.25; 11 boys). Children and caregivers participated in PEERS® for Preschoolers groups, with each group randomly assigned three different baseline periods (1.5, 2, or 2.5 weeks) before beginning. Outcomes and resultsSimulation Modeling Analysis (SMA) revealed concurrent improvements in social and caregiving skills, with subsequent changes in family functioning occurring over the course of this 16-session intervention. Conclusions and implicationsFuture research will need to examine mechanisms of change in PEERS® for Preschoolers for children and caregivers. What this paper addsThere is a dearth of research that specifically examines social skills interventions for young autistic children that incorporates caregivers and examines family functioning as well. This paper is one of the first to evaluate the PEERS® for Preschoolers (P4P) intervention by: 1) exploring changes in child social skills, caregiver efficacy, and family functioning, and 2) analyzing the sequence of improvements in the aforementioned variables to measure systematic change. This pilot study presents results using appropriate methodology for a small sample size of children and caregivers. Results suggested concurrent improvements in social and caregiving skills and subsequent changes in family functioning. These can be built upon for further research on the PEERS® for Preschoolers intervention. This study supports PEERS® for Preschoolers as a feasible intervention that likely contributes to improvements for the child, caregiver in their relationship with their child and parenting styles in general, as well as functioning of the entire family. In sum, this work is essential to furthering the provision of a much needed service of social skills interventions for young autistic children.

Evaluating a Low-Cost Technology to Enable People with Intellectual Disability or Psychiatric Disorders to Initiate and Perform Functional Daily Activities.

People with intellectual disability or psychiatric disorders and cognitive dysfunctions may need assistive technology to maintain and improve their levels of functioning and independence. This study assessed a smartphone-based system to remind the user to initiate functional daily activities (e.g., setting a table for lunch) and perform them without the support of a caregiver. The system was evaluated through a non-concurrent multiple baseline design across two groups of participants. During the intervention sessions, the participants were provided with a system involving a Samsung Galaxy A3 smartphone fitted with the Easy Alarm YouTube application and audio files. The alarm served to remind the participant to carry out a planned activity. Following the reminder, the smartphone presented each of the step instructions preset for the activity. The data showed a statistically significant increase in the number of activities initiated independently from baseline to intervention for all participants. All participants also showed a significant increase in the number of activity steps correctly performed when supported by the smartphone. These results suggest that a low-cost system (i.e., smartphone) can be used to improve independence of people with intellectual disability or psychiatric disorders with cognitive dysfunctions.

Use of everyday technology to promote ambulation in people with intellectual and multiple disabilities

BACKGROUND: People with severe to profound intellectual disabilities and visual or motor impairment tend to be detached and sedentary. OBJECTIVE: The present study assessed a technology-aided intervention to promote ambulation in four people with severe to profound intellectual disability combined with blindness or deafness and spasticity. METHOD: The intervention was introduced according to a non-concurrent multiple baseline design across participants. The participants wore a smartphone fitted with the MacroDroid application at their right or left ankle. This application served to (a) detect and record smartphone’s shake events (i.e., events related to the step responses the participant performed with the leg to which the smartphone was fixed) throughout the study, and (b) automatically deliver stimulation and encouragements/prompts (i.e., in relation to step responses and lack of responding, respectively) during the intervention. RESULTS: Data showed that during the baseline (i.e., prior to the intervention) the participants’ mean frequency of step responses were between 26 and 61 per 5-min session. During the intervention the mean session frequency increased to between 100 and 157. The increase was statistically significant for all participants. CONCLUSION: The aforementioned technology-aided intervention may be a useful tool for promoting ambulation in people like those involved in this study.

POWER: A Caregiver Implemented Mand Training Intervention.

The development of a vocal mand repertoire is often delayed or deficient in children with an autism spectrum disorder. Utilizing caregivers as behavior change agents to address this core deficit may be advantageous as more learning opportunities can be incorporated in daily routines. A plethora of literature exists on teaching caregivers to promote communication with their children; however, many of these studies use behavioral skills training that can be resource-intensive. This study evaluated the effectiveness of video modeling with voice-over and on-screen text, without researcher mediation, as an alternative to behavioral skills training for teaching caregivers to teach vocal mands to their 2- to 5-year-old children with an autism spectrum disorder. The video model described mand training with an echoic prompt (Greer & Ross, 2008; Kodak & Clements, 2009), using a mnemonic (POWER: Play, Offer, Wait, Encourage, and Reinforce). Results of our nonconcurrent multiple baseline design across three dyads indicates that video modeling was effective in increasing all three caregivers' mand training fidelity, and this correlated to small increases in independent mands with some of the child participants when training occurred less than 1 hr per week. We discuss implications for practice and areas for future research.

App-based data collection, mental imagery, and naming performance in adults with aphasia

Background and purposeNaming impairments are often found in aphasia. Combining mHealth technology with mental imagery may offer new insights into novel approaches to naming interventions in persons with aphasia. The aims of this study are to (1) explore whether mental imagery can improve performance during a naming task in adults with aphasia; and, (2) demonstrate the use of app-based data collection for research in aphasia rehabilitation through utilization of an app designed specifically for this study. Materials and methodsA single subject non-concurrent multiple baseline design across participants was utilized. Four participants with anomic and conduction aphasia were included. Each participant's percentage of naming accuracy was measured before the initiating intervention to establish a baseline level of performance. ResultsPer overlap metrics, two of the participants demonstrated a strong effect in improving naming from baseline to intervention on items using the app. Two participants showed no effect in naming accuracy from the imagery intervention. ConclusionSome participants showed improvement in naming items following an imagery script, suggesting that this complementary health practice should continue to be explored. Additionally, this study demonstrates the successful use of app-based data collection.

Improving cognition in severe mental illness by combining cognitive remediation and transcranial direct current stimulation: study protocol for a pragmatic randomized controlled pilot trial (HEADDSET)

BackgroundA fundamental challenge for many people with severe mental illness (SMI) is how to deal with cognitive impairments. Cognitive impairments are common in this population and limit daily functioning. Moreover, neural plasticity in people with SMI appears to be reduced, a factor that might hinder newly learned cognitive skills to sustain. The objective of this pilot trial is to investigate the effects of cognitive remediation (CR) on cognitive and daily functioning in people dependent on residential settings. In addition, transcranial direct current stimulation (tDCS) is used to promote neural plasticity. It is expected that the addition of tDCS can enhance learning and will result in longer-lasting improvements in cognitive and daily functioning.MethodsThis is a pragmatic, triple-blinded, randomized, sham-controlled, pilot trial following a non-concurrent multiple baseline design with the participants serving as their own control. We will compare (1) CR to treatment as usual, (2) active/sham tDCS+CR to treatment as usual, and (3) active tDCS+CR to sham tDCS+CR. Clinical relevance, feasibility, and acceptability of the use of CR and tDCS will be evaluated. We will recruit 26 service users aged 18 years or older, with a SMI and dependent on residential facilities. After a 16-week waiting period (treatment as usual), which will serve as a within-subject control condition, participants will be randomized to 16 weeks of twice weekly CR combined with active (N = 13) or sham tDCS (N = 13). Cognitive, functional, and clinical outcome assessments will be performed at baseline, after the control (waiting) period, directly after treatment, and 6-months post-treatment.DiscussionThe addition of cognitive interventions to treatment as usual may lead to long-lasting improvements in the cognitive and daily functioning of service users dependent on residential facilities. This pilot trial will evaluate whether CR on its own or in combination with tDCS can be a clinically relevant addition to further enhance recovery. In case the results indicate that cognitive performance can be improved with CR, and whether or not tDCS will lead to additional improvement, this pilot trial will be extended to a large randomized multicenter study.Trial registrationDutch Trial Registry NL7954. Prospectively registered on August 12, 2019.

Increasing passive compliance to wearing a facemask in children with autism spectrum disorder.

The current study taught 6 children with autism spectrum disorder (ASD) to increase passive compliance of wearing a facemask across sequentially increasing durations of time. A changing‐criterion design embedded within a nonconcurrent multiple baseline design was used to evaluate the effectiveness of a resetting differential reinforcement of other behavior (DRO) without escape extinction procedure on passive compliance. Terminal probe sessions determined DRO fading intervals. Results showed that 2 participants acquired mastery level passive compliance (30 min) without fading during the initial baseline sessions. The remaining 4 participants acquired mastery level passive compliance following fading intervals within the DRO intervention. Participants' passive compliance generalized across 2 novel settings. This study replicates previous studies and extends empirical support for the use of DRO without escape extinction interventions for increasing passive compliance with medical devices in children with ASD.