Non-concurrent Multiple Baseline Design Research Articles

People with Neuro-motor Impairment, Lack of Speech, and General Passivity Can Engage in Basic Forms of Activity and Communication with Technology Support

Abstract Objectives People with neuro-motor impairment, lack of speech and general passivity live in a marginalized and isolating condition. This study used a technology-aided program to help three of these people achieve basic activity (i.e., accessing music videos and listening to stories and/or answering questions) and communication (i.e., video calling or sending messages to preferred partners). Methods The study was carried out according to a non-concurrent multiple baseline design across participants. During the intervention, the participants were provided with the technology system that entailed a tablet and two touch or two optic sensors. Within each session, the tablet presented the participants with choice periods (i.e., periods in which they could choose between music videos and communication with distant partners) interspersed with stories plus questions or questions periods. Results During the baseline (without the technology system), the participants were not able to make choices (failing to access music videos or communication events) or to answer questions. During the intervention sessions, all participants used the technology successfully to access music videos and communication events and to answer questions independently. Conclusions The results suggest that simple technology can be adapted to help people like the participants of this study achieve basic forms of functional activity and communication.

Effects of Serial Multiple Exemplar Training on Bidirectional Naming in Children with Autism

AbstractThis study examined the effect of a serial multiple exemplar training (S-MET) procedure on bidirectional naming (BiN) in four preschool children diagnosed with autism spectrum disorder (ASD). A non-concurrent multiple baseline design was used to evaluate the effects of training listener and speaker behavior for one stimulus at a time until BiN occurred. When BiN occurred, probes were conducted to measure whether generalization occurred across settings and people. Three out of four participants’ responding met the mastery criterion for BiN, while the fourth participant improved her performance. The results of this study suggest that S-MET may be a promising intervention and contribute to our knowledge about learning histories required for BiN.

Professional Development Effects on Early Intervention Providers’ Implementation of Home Visiting Practices

A non-concurrent multiple baseline design across four early intervention providers was used to examine functional relations between job-embedded professional development (PD), including practice-based coaching (PBC), and providers’ fidelity of implementation of home visiting practices for embedded intervention. Four providers with one to two caregivers and their toddler with disabilities or developmental delays participated. The primary dependent measure was the number of essential home visiting practices providers implemented with fidelity. Results from visual analyses showed a functional relation between job-embedded PD and the number of essential home visiting practices implemented with fidelity for three of four providers. Provider and caregiver social validity data indicated PD and home visiting practices and embedded intervention were appropriate, feasible, and useful. Results provide promising evidence for job-embedded PD, including PBC, to support providers’ fidelity of implementation of home visiting practices for embedded intervention. Implications for future research and practice are discussed.

CICO-Secondary: A Single-Case Experimental Study in High School

Check-in/check-out (CICO) is an evidence-based multicomponent intervention widely implemented in elementary and middle schools. The purpose of this study was to evaluate whether an adapted CICO intervention, with CICO components designed to be more developmentally appropriate for adolescents and contextually relevant for high schools, could be implemented with procedural fidelity and improve outcomes for students with and at risk for disabilities. The study included three ninth-grade students (two with Individualized Education Programs) in one U.S. public high school. We used a non-concurrent multiple baseline design conducted over two academic years during the COVID-19 pandemic to experimentally evaluate the effects of CICO-Secondary on student academic engagement. Results demonstrated that students participated with adequate procedural fidelity and that there was a functional relation between implementation of CICO-Secondary and improved student academic engagement. Students and school personnel also perceived CICO-Secondary to be socially valid. Implications for both future research and practice are discussed.

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.

Using video modeling to teach the picture exchange communication system

The picture exchange communication system (PECS) is an evidence-based communication intervention designed to improve communication skills in people with limited to no functional speech. Because of this, professionals frequently look for opportunities to receive training in how to implement PECS. Though most training methodologies have included robust, and time intensive, training methodologies, one recent study used video modeling (VM) with voice-over instructions and text descriptions to train three future professionals in the implementation of PECS. Thus, to find even more efficient and effective training methodologies, this study aimed to train future professionals in the first three phases of PECS using VM alone and, if necessary, verbal feedback. A nonconcurrent multiple baseline design across three participants was used in the study. The results indicated all three participants demonstrated an immediate change in skills following VM alone, with only one participant requiring brief feedback in Phase 1. This was further evidenced by large effect sizes. Thus, results indicate that training future professionals using VM was both more efficient and equally effective when compared to previous training methodologies.

Using Simple Interactive Technology to Help People with Intellectual and Visual Disabilities Exercise Functional Physical Responses: A Case Series Study

The study assessed a new interactive technology system for helping six people with intellectual and visual disabilities exercise relevant physical responses embedded within a fairly straightforward activity (i.e., placing objects in containers). Activity responses consisted of the participants taking objects from the floor or a low shelf and placing those objects in a container high up in front of them (thus bending their body and legs and stretching their arms and hands). The technology involved a portable computer, a webcam, and three mini speakers whose basic functions included monitoring the participants’ responses, delivering preferred stimulation contingent on the responses and verbal encouragements/prompts for lack of responses, and assisting in data recording. The study was conducted following a non-concurrent multiple baseline design across participants. During baseline (i.e., when the system was used only for data recording), the participants’ mean frequency of responses per session varied between zero and nearly 12. During intervention (i.e., when the system was fully working), the participants’ mean frequency of responses per session increased to between about 34 and 59. Mean session duration varied between nearly 10 and over 14 min. The new system may be a valuable tool for supporting relevant physical activity engagement in people with intellectual and multiple disabilities.

A Digital Music-Based Mindfulness Intervention for Black Americans With Elevated Race-Based Anxiety: A Multiple-Baseline Pilot Study.

Race-based anxiety is a substantial health issue for the Black community. Although mindfulness interventions have demonstrated efficacy for alleviating anxiety, three central barriers prevent Black Americans from accessing existing mindfulness treatments: high costs, excessive time commitments, and limited cultural relevance. There is a need for novel mindfulness interventions for the Black community that can overcome these barriers. The goal of this web-based study was to examine the preliminary efficacy, feasibility, and acceptability of a novel digital music-based mindfulness intervention for middle-to-low-income Black Americans with elevated race-based anxiety. This study used a nonconcurrent multiple-baseline design (n=5). The intervention featured contributions from Lama Rod Owens (a world-renowned meditation teacher and LA Times best-selling author) and Terry Edmonds (the former chief speechwriter for President Bill Clinton). We examined the effect of the intervention on state anxiety and assessed its feasibility and acceptability using quantitative and qualitative measures. Results revealed that administration of the intervention led to significant decreases in state anxiety (Tau-U range -0.75 to -0.38; P values<.001). Virtually all feasibility and acceptability metrics were high (ie, the average likelihood of recommending the intervention was 98 out of 100). This study offers preliminary evidence that a digital music-based mindfulness intervention can decrease race-based anxiety in Black Americans. Future research is needed to replicate these results, test whether the intervention can elicit lasting changes in anxiety, assess mechanisms of change, and explore the efficacy of the intervention in real-world contexts.

Motivating children with feeding disorders to self‐feed: An evaluation of using differential reinforcement and manipulation of establishing operations to increase self‐feeding

AbstractSelf‐feeding is a behavioral cusp vital to independence, growth, and development. Previous studies demonstrate that interventions like escape extinction in the form of physical guidance are effective at increasing self‐feeding in children with feeding disorders. However, these interventions may not be effective for all children. In the present study, we evaluated the effects of a treatment package that involved increasing the quality of feeder attention and access to tangibles to decrease the comparative value of escape from the self‐feeding demand for two children with feeding disorders using a nonconcurrent multiple baseline design. Despite demonstrating the skills to self‐feed preferred foods and consume target foods, neither child self‐fed target foods independently. Following differential reinforcement with the manipulation of establishing operations, both children demonstrated improvement in self‐feeding bites of target foods. In addition, caregivers were trained to implement the protocol with high procedural integrity.

Effect of Unified Protocol on neuroticism, emotion regulation skills, and symptom severity—A case series

BackgroundThere has been a shift from single disease protocols to interventions that address shared vulnerabilities across disorders with high comorbidity. Unified Protocol (UP) is an emotion-focused transdiagnostic intervention that addresses neuroticism, a shared mechanism identified in emotional disorders by enhancing emotion regulation skills. In this study, we attempted to understand the effect of the (UP) on symptom severity, emotion regulation, and neuroticism. MethodsA non-concurrent multiple baseline design was adopted. Six clients with a primary diagnosis of an anxiety disorder were randomly assigned to a 2, 3, or 4-week baseline period, following medication stabilization for 4 weeks. Following the baseline period, UP was delivered over 15–18 sessions. Neuroticism and emotion regulation were assessed at baseline, post, and follow-up. Anxiety severity was measured weekly by both an independent rater and on self-report. ResultsOf the 6 clients randomized, 3 completed the intervention. Visual analysis was used to examine changes in symptom severity and Reliable Change Index (RCI) was used to examine changes in scores on neuroticism and emotion regulation across time points for the 3 completers. Reliable change was observed in 1 out of 3 clients for neuroticism and in 2 out of 3 clients for emotion regulation skills. Change in slope, and level of symptom severity was observed across participants. ConclusionsUP is a parsimonious approach to addressing co-morbidities. Our findings support the role of emotion regulation skills in the management of anxiety. A larger sample is required to establish these findings more robustly and support generalization of findings.

Trauma-focused treatment for traumatic stress symptoms in unaccompanied refugee minors: a multiple baseline case series.

Unaccompanied refugee minors (URMs) are at increased risk of developing mental health problems, such as symptoms of posttraumatic stress disorder (PTSD) and depression. In addition, URMs face several barriers to mental health care. Few studies have evaluated trauma-focused interventions for URMs that target these issues. The current study evaluated a multimodal trauma-focused treatment approach for URMs. It aimed to provide an initial indication of the effectiveness of this treatment approach and to provide a qualitative evaluation assessing treatment satisfaction of the participating URMs. A mixed-methods study was conducted among ten URMs, combining quantitative data with qualitative data through triangulation. Quantitative data were collected using a non-concurrent multiple baseline design in which repeated, weekly assessments were carried out during a randomized baseline period, during treatment, and during a 4-week follow-up period. Questionnaires assessing PTSD (Children's Revised Impact of Event Scale) and symptoms of depression (The Patient Health Questionnaire-9, modified for adolescents) were used. In addition, treatment satisfaction was measured post-treatment using a semi-structured interview. During the qualitative evaluation, all but one URM noted they found the trauma-focused treatment approach useful and felt the treatment had positively impacted their wellbeing. However, the results of the quantitative evaluation did not show clinically reliable symptom reductions at posttest or follow-up. Implications for clinical practice and research are discussed. The current study presents our search in developing a treatment approach for URMs. It adds to the current knowledge about methodological considerations in evaluating treatments for URMs, the potential effects of trauma-focused treatments on URMs, and the implementation of treatments for URMs.Clinical trial registration: The study was registered in the Netherlands Trial Register (NL8519), 10 April 2020.

A pilot multiple-baseline study of a mobile cognitive behavioral therapy for the treatment of eating disorders in university students.

Eating disorders (EDs) are serious psychiatric disorders associated with substantial morbidity and mortality that are prevalent among university students. Because many students do not receive treatment due to lack of access on university campuses, mobile-health (mHealth) adaptations of evidence-based treatments represent an opportunity to increase treatment accessibility and engagement. The purpose of this study was to test the initial efficacy of Building Healthy Eating and Self-Esteem Together for University Students (BEST-U), which is a 10-week mHealth self-guided cognitive-behavioral therapy (CBT-gsh) app that is paired with a brief 25-30-min weekly telehealth coaching, for reducing ED psychopathology in university students. A non-concurrent multiple-baseline design (N = 8) was used to test the efficacy of BEST-U for reducing total ED psychopathology (primary outcome), ED-related behaviors and cognitions (secondary outcomes), and ED-related clinical impairment (secondary outcome). Data were examined using visual analysis and Tau-BC effect-size calculations. BEST-U significantly reduced total ED psychopathology and binge eating, excessive exercise, and restriction (effect sizes ranged from -0.39 to -0.92). Although body dissatisfaction decreased, it was not significant. There were insufficient numbers of participants engaging in purging to evaluate purging outcomes. Clinical impairment significantly reduced from pre-to-post-treatment. The current study provided initial evidence that BEST-U is a potentially efficacious treatment for reducing ED symptoms and ED-related clinical impairment. Although larger-scale randomized controlled trials are needed, BEST-U may represent an innovative, scalable tool that could reach greater numbers of underserved university students than traditional intervention-delivery models. Using a single-case experimental design, we found evidence for the initial efficacy of a mobile guided-self-help cognitive-behavioral therapy program for university students with non-low weight binge-spectrum eating disorders. Participants reported significant reductions in ED symptoms and impairment after completion of the 10-week program. Guided self-help programs show promise for filling an important need for treatment among university students with an ED.

The effect of brief acceptance and commitment training on values-based behaviors of Japanese parents of children with autism

The purpose of this study was to examine the effects of brief acceptance and commitment training (ACT) on overt values-based behaviors, psychological flexibility, psychological well-being, and parental adherence of four Japanese mothers of children with autism. A non-concurrent multiple baseline design across participants with pre- and post-measures was used in this study. All four participants received five 45–60 min of online ACT sessions. The level of psychological flexibility and psychological well-being were assessed using a 6-PAQ and PWBS-42, respectively. In addition, a social validity questionnaire assessed the feasibility and acceptability of the ACT. To establish clinically significant change, between-case standardized mean differences and non-overlap of all pairs (NAP) were calculated for overt values-based behaviors. Reliable change index was calculated for the reported scores of 6-PAQ and PWBS-42. The NAP analysis demonstrated that three out of four participants showed moderate to strong improvement in overt values-based behaviors and some participants showed a reliable increase in reported scores on psychological well-being. The results suggest that ACT was effective and acceptable for the Japanese population. The paper highlights the importance of cultural variables in designing, implementing, and analyzing data and provides direction for future studies.

Use of Augmentative and Alternative Communication by Individuals with Rett Syndrome Part 1: Page-Linking.

Although the last decade has welcomed evidence that individuals with Rett syndrome (RTT) can communicate using alternative and augmentative communication (AAC), less is known about effective procedures for teaching various component skills required for expressive communication of individuals with complex communication needs. The purpose of the current study was to evaluate the effects of systematic individualized instruction procedures on the page-linking skills of individuals with RTT. A nonconcurrent multiple baseline design across participants was used to evaluate independent and accurate responding utilizing both a high-tech and low-tech AAC device for three participants. All sessions were conducted in the participants' homes by their parents with remote coaching from a researcher via telehealth. Results indicated that for all three participants, individualized procedures that included behavior chaining, differential reinforcement, and delayed prompting were effective for teaching page-linking in both a high-tech and a low-tech AAC device. Directions for future research and practice are discussed.

Supervision Strategies for Treatment Fidelity and Job Satisfaction in Applied Behavior Analysis Services

Supervising behavior technicians in the implementation of services derived from the science of applied behavior analysis with children diagnosed with autism spectrum disorder (ASD) is a common practice for behavior analysts. However, there is limited training available on supervision strategies for those applying this model of services. Lack of training can lead to ineffective and inconsistent supervisory practices, resulting in low rates of job satisfaction for supervisees and variable fidelity in treatment implementation. The quality of supervision can improve job satisfaction and treatment fidelity. This study was conducted using a nonconcurrent multiple baseline design across participants to evaluate the effects of an evidence-based approached to supervision on treatment fidelity and job satisfactory for three behavior technicians providing services for a child with ASD. Each of the three technicians demonstrated improved levels of treatment fidelity and increased job satisfaction across several facets of their job during the intervention and maintenance phase. Implications of these findings, limitations of this study, and suggestions for future research are included.

Efficacy And Acceptability Of Virtual Reality Imagery Rescripting For Ptsd Due To Childhood Sexual Abuse: A Multiple Baseline Study

This study piloted the efficacy and acceptability of Virtual Reality Imagery Rescripting (VR-ImRs) compared to conventional Imagery Rescripting (ImRs) for PTSD due to childhood sexual abuse (CSA). Eight adult patients with clinician-rated PTSD due to CSA as their primary diagnosis participated, of whom six completed the full treatment. A non-concurrent multiple baseline design with cross-over elements was used, with randomly assigned baseline lengths and treatment conditions. After baseline and a 5-session ‘education and exploration’ phase, six sessions of either ImRs or VR-ImRs were given, followed by another six sessions of the opposite treatment condition and a 5-week follow-up without treatment. The primary outcome was PTSD symptoms (PCL-5), and secondary outcomes were negative and positive emotions (added PCL-5 items), anxiety and depressive symptoms (HADS) and trauma-related cognitions (PTCI). Data were analyzed with mixed regression. Results showed a significant linear reduction of trauma symptoms and negative emotions only during ImRs. No significant treatment effects on positive emotion, anxiety and depressive symptoms were found for both treatment conditions. Both treatment conditions showed significant positive effects on trauma-related cognitions. This study does not support the efficacy of VR-ImRs in reducing PTSD symptoms. Possibly VR-ImRs keeps people from reprocessing their memories, making it less effective.

Using the high-probability instructional sequence to improve initiation and completion of low-probability instructions in young autistic children

This study examined the use of the high-probability (high-p) instructional sequence during pre-academic or academic activities for three young children diagnosed with autism spectrum disorder (ASD) served in public elementary schools. Specifically, we examined the effects of the high-p instructional sequence on the children’s initiation and completion of low-probability (low-p) instructions, implemented by their classroom teachers. A nonconcurrent multiple-baseline design across participants was used to evaluate the intervention outcomes. The results indicated that the high-p instructional sequence may be an effective antecedent-based intervention for autistic children who typically initiate the low-p instructions but have difficulty completing the instructions. A strong magnitude of effect was shown for initiation across children. For one child, initiation and completion increased during high-p, and the improvement was maintained above criterion levels when high-p instructions in sequence were faded. For two children, we found high levels of initiation but variable performance in completion during high-p. The use of programmed reinforcement for one child suggests that for autistic children who do not often initiate the low-p instructions, the addition of programmed reinforcement may be needed to increase completion of low-probability instructions.

Teaching adolescents with autism how to use prosocial lies in conversation

Individuals with Autism Spectrum Disorder (ASD) commonly have deficits in social communication and interactions. Therefore, numerous studies have been published over the last few decades which have centred on prosocial skills development for children and adolescents identified as having ASD. One skill that has become more common in the literature, is that of prosocial deception. However, a need still exists for a more effective way to teach this skill. Therefore, this study sought to instruct adolescents with ASD how to use prosocial lies when engaging in various social interactions via behavioural skills training (BST). A nonconcurrent multiple baseline design across participants was used, and results indicated adolescents were able to successfully learn how to tell prosocial lies when taught either virtually or in-person using BST. All participants significantly increased their ability to tell a prosocial lie while appearing engaged in a conversation through the use of modeling, rehearsal, and feedback. Additionally, the treatment resulted in the participants acquiring the skills needed to engage in conversations outside of their restricted interests. Implications of this research along with limitations and future directions will also be discussed.

FAST CBT for pediatric OCD: A multiple-baseline controlled pilot trial of parent training in exposure and response prevention delivered via telehealth.

The current study utilized a single case series, non-concurrent multiple baseline design to examine the efficacy of training parents via telehealth videoconferencing in exposure and response prevention (ERP) for home delivery of the treatment for their children and adolescents with obsessive compulsive disorder (OCD). There were nine participants aged 8 to 14 years who had received a primary diagnosis of OCD. The design involved a series of AB replications, whereby following pre-treatment assessments participants were randomly assigned to either a 2-week (n = 4) or 3-week (n = 5) baseline condition with weekly monitoring of their child's OCD symptoms. Following baseline, parents participated four weekly telehealth parent-training modules in delivering FAST (Families Accessing Skills Training) cognitive behavior therapy (CBT) with ERP (CBT-ERP) to children with OCD via videoconferencing with the clinician. Primary outcome measures were OCD symptom severity, diagnostic severity, and global functioning, which were assessed post-treatment and at 2 month follow-up. The stability of the baseline period from pre-treatment to week 2 (for the 2-week condition) or to week 3 (for the 3-week condition) was established as there were no significant differences across baseline scores for parent target obsessions or parent target compulsions ratings. Significant improvements on the primary outcomes of clinician assessed symptom severity, diagnostic ratings, and global functioning were observed from baseline to post-treatment, and continued to 2 months follow-up. These data suggest that brief, parent training in FAST CBT-ERP via telehealth provides an overall effective intervention that is likely to be of most benefit to children and youth who are mild to moderate in severity.