Single-case Methodology Research Articles

Individual‐level interventions for alcohol‐related violence: A rapid evidence assessment

Alcohol-related violence is of major concern to society. Around half of all violent crimes are alcohol related, and yet interventions for alcohol-related violence are under-developed. Often, offenders receive treatment for substance use or violence, but not the two in nexus. My aim was to conduct a Rapid Evidence Assessment of interventions with a focus on treating established nonsexual violence in the context of alcohol use, to describe the content of these interventions, where they take place and their effectiveness in reducing alcohol problems and/or violence. The electronic databases Embase, Medline, National Criminal Justice Reference Service, Cumulative Index to Nursing and Allied Health Literature were searched together with the Campbell Collaboration; Cochrane Reviews and selected government websites using terms for alcohol, violence and treatment/interventions. The search excluded sexual and intimate partner violence. The focus was on psychosocial interventions with people already in difficulties, not prevention. All empirical study types with people of any age and in any setting (criminal justice, health, social services or education) were included. The principal outcomes of interest were change in alcohol use, violence and alcohol-related violence. Only four studies of two different interventions were identified. Control of Violence for Angry Impulsive Drinkers has been evaluated with small samples using a nonequivalent comparison group and a single case methodology. Changes were evident on measures of alcohol-related aggression. In a randomised controlled trial, SafERteens participants showed greater improvements in attitudes to alcohol and violence compared with a leaflet only condition. Directions for developing interventions based on alcohol and aggression research are discussed. Interventions targeting primarily alcohol consumption, primarily violence and alcohol-related violence in nexus should be compared. In evaluating these interventions, robust outcome measures should be used across studies to allow comparisons to be made. Skills for coping with perceived provocation may be taught, so that nonviolent options are available and so that they become more accessible when people are under the influence of alcohol. Alcohol's effect on reducing self-awareness may be counteracted by teaching mindfulness techniques and the ability to 'act sober' in provocative situations. Setting individual implementation intentions may facilitate harm avoidance in high-risk social situations through preplanning of specific sensible behavioural strategies.

Bilateral dorsal foot pain in a young tennis player managed by neurodynamic treatment techniques

Exercise-related lower limb pain represents one of the most common presentations in sports medicine practice. This is usually caused by musculoskeletal overuse injuries but not uncommonly, a neuropathic cause may be suspected. A review of the literature revealed that peripheral neuropathic pain has never been documented in a child. It is possible that peripheral neuropathic pain of spinal origin may be more prevalent in children than previously recognized. This case report describes the presentation of a 12 year old tennis player with bilateral dorsal foot pain, who presented with positive findings of peripheral nerve sensitization which was successfully managed using neurodynamic treatment techniques. Differential diagnoses are considered and treatment and management described. A discussion of the clinical reasoning which led to the patient’s diagnosis is included. This case report suggests the effectiveness of neurodynamic treatment in a child with bilateral foot pain who fulfilled published criteria for peripheral nerve sensitization. However, the single case methodology employed in this study limits generalization of its findings. Further studies are warranted to investigate the role of neurodynamics in musculoskeletal pain disorders in children.

Innovation by harmonizing continuity and change

PurposeThe objective of this paper is to present a broad‐based tool primarily for the use of practitioners at the senior and middle management levels, to analyze the innovation management processes within their organizations and assess their impact on innovation and firm performance. It is contended that these processes are dichotomous because of the invariable tension between continuity and change‐related aspects to be coped with.Design/methodology/approachA single case (Moser Baer India Limited, an Indian firm and one of the world's large manufacturers of optical storage media) illustrating the use of a flowing stream strategy framework is presented. The theory that is the basis of the approach is not expounded at length in the interests of the basic target audience.FindingsThe paper is an attempt to present a structured approach to strategy making. Realizing the hazards of organizational impediments in the implementation of strategy, only an illustrative approach is been indicated, paving the way for further investigation.Research limitations/implicationsThe limitations associated with a single case methodology may prevail to some extent. The data are context‐bound; however, no attempt to draw general implications has been made. The purpose is more to present the use of a practical tool rather than to advance theoretical knowledge.Practical implicationsThe tool presented may be useful across a range of organizations, with minor adaptations.Originality/valueThe paper is original and adds value in terms of the above.

The Lumberworks Agent: When Trust and Integrity Matter to the Agent

The problem of the principal-agent relationship is one that has plagued human transactions since time immemorial. Information asymmetry and moral hazard, (Eisenhardt, 1989) make it difficult to achieve the levels of trust that could reassure the principal that the agent’s interest is aligned to his, especially when viewed against the background understanding of man as ‘homo oeconomicus’, characterised by an utility maximizing perspective (Jensen and Meckling, 1976). Fligstein and Freeland (1995) identified the problems as issues of internal control, especially of hierarchy and motivation, and mention that they commonly occur where there is management on one side and workers on the other, or ownership on one side with control on the other, or division of labour into several levels of management.Agency theory postulates that once incentives are appropriately structured and information is made more symmetrical, agents will work in favour of their principals (Eisenhardt, 1989). Time and experience have shown that there may be other variables at work and that there is a need to exercise caution in applying agency theory (Donaldson and Davis, 1991). A single case study of Lumberworks Ltd. is used to explore, validate and extend these ideas, following the suggestion by Tosi and Gomez Mejia (1989) that there may be need to research agency theory using other behavioural science methodologies other than the psychometric approach commonly favoured, in order to enrich the understanding of the effects of monitoring and incentive alignment efforts. According to Yin (1984), looking at a phenomenon in a real life context makes it more intelligible and guides our further understanding of its confines and its reaches.Thus, using single case methodology, this paper suggests that monitoring and incentive structures, the most common responses to principal-agent concerns, are limited in their effectiveness and that a trust-building approach is what is needed to achieve the much sought after alignment of interests. Since trust can only be built where there is integrity, it would seem that integrity is what really matters to the agent, and a culture of integrity is what will grow mutual trust in such a way as to resolve all the conflicts thrown up within the agency relationship.The paper also suggests that there may be some institutional differences across cultures which affect principal-agent relationships and that, in Nigeria in particular, and perhaps for countries in similar emergent economic conditions, a deinstitutionalization perspective may be very useful. In such a case, the trust-building approach based on fostering a culture of integrity still is the solution, since it tends to generate a deeper and more long-lasting solution to both agency and institutionalization problems related to instances of negative work ethic. Further research could be aimed at exploring the distinct steps towards building cultures of integrity and the possibilities of deinstitutionalizing negative and or self-interested attitudes and replacing them with productive and other-regarding ones through education and training activity.

Rehabilitation Treatments for Adults with Behavioral and Psychosocial Disorders Following Acquired Brain Injury: A Systematic Review

This review was aimed at systematically investigating the treatment efficacy and clinical effectiveness of neurobehavioral rehabilitation programs for adults with acquired brain injury and making evidence-based recommendations for the adoption of these rehabilitation trainings. Using a variety of search procedures, 63 studies were identified and reviewed using a set of questions about research methods, treatments, results and outcomes for the 1,094 participants. The 63 studies included treatments falling into three general categories: approaches based on applied behavior analysis, interventions based on cognitive-behavior therapy (CBT), and comprehensive-holistic rehabilitation programs (CHRPs). Considerable heterogeneity exists in the reviewed literature among treatment methods and within reported sample subjects. Despite the variety of methodological concerns, results indicate that the greatest overall improvement in psychosocial functioning is achieved by CHRP that can be considered a treatment standard for adults with behavioral and psychosocial disorders following acquired brain injury. Both approaches based on applied behavior analysis and CBT can be said to be evidence-based treatment options. However, findings raise questions about the role of uncontrolled factors in determining treatment effects and suggest the need for rigorous inclusion/exclusion criteria, with greater specification of theoretical basis, design, and contents of treatments for both interdisciplinary-comprehensive approaches and single-case methodologies.

“Shallow Draughts Intoxicate the Brain”: Lessons from Cognitive Science for Cognitive Neuropsychology

This article presents a sobering view of the discipline of cognitive neuropsychology as practiced over the last three or four decades. Our judgment is that, although the study of abnormal cognition resulting from brain injury or disease in previously normal adults has produced a catalogue of fascinating and highly selective deficits, it has yielded relatively little advance in understanding how the brain accomplishes its cognitive business. We question the wisdom of the following three "choices" in mainstream cognitive neuropsychology: (a) single-case methodology, (b) dissociation between functions as the most important source of evidence, and (c) a central goal of diagramming the functional architecture of cognition rather than specifying how its components work. These choices may all stem from an excessive commitment to strict and fine-grained modularity. Although different brain regions are undoubtedly specialized for different functions, we argue that parallel and interactive processing is a better assumption about cognitive processing. The essential goal of specifying representations and processes can, we claim, be significantly assisted by computational modeling which, by its very nature, requires such specification.

The Effects of a Monetary Incentive System on Work Performance of Mental Health Counselors

Improving the productivity of mental health counselors was investigated with the use of an incentive system. Ten Masters-level mental health clinicians (5 females, 5 males) with a range of 1.5 to 17 years experience participated in the study. Single-case and between-group methodologies were used to assess the effects of the incentive on the number of direct client contact sessions conducted per day. Incentive payments were provided to clinicians above a minimum number per two-week pay period. The number of session credits improved from a baseline of 73.6 to a mean of 85.9 during the program.

Evaluation of a treatment programme for alcohol‐related aggression

The development of effective treatments for alcohol-related aggression and violence is important in binge drinking cultures, as in parts of the UK.Aim The aim was to evaluate the progress and experience of 10 participants in Control of Violence for Angry Impulsive Drinkers (COVAID) using a single case methodology. Participants completed 10 individual weekly sessions with trained facilitators following the COVAID manual. Change scores on psychometric questionnaires were examined by calculating clinical significance and reliability of change. Self-reports of alcohol consumption and aggression were examined. Follow-up data on convictions were collected. Participants were asked their opinions about COVAID. Scores on the Alcohol-Related Aggression Questionnaire (ARAQ) improved for nine participants; change was both clinically significant and reliable in five cases. Nine participants improved on the Controlled Drinking Self-Efficacy Scale (CDSES), with seven showing clinically significant improvement. Six participants reported a reduction in alcohol consumption from the first to the second half of the programme. At a mean of 29 weeks post-treatment, none of the participants had been reconvicted for a violent offence. Participants reported finding COVAID useful and interesting. Overall, our findings support the possibility that COVAID may assist in reducing alcohol-related violence and violent offending.

The use of a psychological intervention to increase adherence during factor administration in a child with haemophilia

While factor replacement treatments allow children with haemophilia to lead near normal lives, these treatments can be difficult to administer, especially to younger children. The intervenous infusions required by these treatments can be painful and result in children attempting to avoid treatment by exhibiting a range of inappropriate behaviours. Their children's uncooperative behaviour during prophylaxis was cited by parents as a significant barrier to treatment adherence. This study provides a case illustration of the use of psychological interventions to increase adherence during factor administration. Single-case methodology was used to demonstrate the effectiveness of the psychological interventions including counterconditioning, distraction, and positive differential reinforcement. The intervention resulted in increased adherence across several months of intervention. Psychological interventions can be effectively used by caregivers and care providers to increase adherence in the treatment of haemophilia.

Rating the methodological quality of single-subject designs and n-of-1 trials: Introducing the Single-Case Experimental Design (SCED) Scale

Rating scales that assess methodological quality of clinical trials provide a means to critically appraise the literature. Scales are currently available to rate randomised and non-randomised controlled trials, but there are none that assess single-subject designs. The Single-Case Experimental Design (SCED) Scale was developed for this purpose and evaluated for reliability. Six clinical researchers who were trained and experienced in rating methodological quality of clinical trials developed the scale and participated in reliability studies. The SCED Scale is an 11-item rating scale for single-subject designs, of which 10 items are used to assess methodological quality and use of statistical analysis. The scale was developed and refined over a 3-year period. Content validity was addressed by identifying items to reduce the main sources of bias in single-case methodology as stipulated by authorities in the field, which were empirically tested against 85 published reports. Inter-rater reliability was assessed using a random sample of 20/312 single-subject reports archived in the Psychological Database of Brain Impairment Treatment Efficacy (PsycBITETM). Inter-rater reliability for the total score was excellent, both for individual raters (overall ICC = 0.84; 95% confidence interval 0.73–0.92) and for consensus ratings between pairs of raters (overall ICC = 0.88; 95% confidence interval 0.78–0.95). Item reliability was fair to excellent for consensus ratings between pairs of raters (range k = 0.48 to 1.00). The results were replicated with two independent novice raters who were trained in the use of the scale (ICC = 0.88, 95% confidence interval 0.73–0.95). The SCED Scale thus provides a brief and valid evaluation of methodological quality of single-subject designs, with the total score demonstrating excellent inter-rater reliability using both individual and consensus ratings. Items from the scale can also be used as a checklist in the design, reporting and critical appraisal of single-subject designs, thereby assisting to improve standards of single-case methodology.

Pesquisas em psicoterapia: seções especiais de periódico (1981 a 1994)

O artigo apresenta pesquisas em psicoterapia e pretende oferecer uma visão qualitativa do desenvolvimento e das tendências da área. Analisa nove seções especiais sobre o tema publicadas no período de 1981 a 1994 em um periódico da American Psychological Association (APA) considerado de ponta em pesquisas em psicoterapia. Verifica ênfase na busca de evidência científica e na articulação da pesquisa com a prática clínica. Observa grande produção no período e avanços na área principalmente quanto a pesquisas de caso único. Verifica que os questionamentos centrais seguem desafiando os pesquisadores.

Evaluating innovative treatments in forensic mental health: A role for single case methodology?

The rapid development of new forensic mental health services and treatments has created a demand for research and evidence relating to the effectiveness of interventions. Unfortunately, the literature on outcomes of treatments for mentally disordered offenders is sparse, compared with the substantial ‘what works’ literature regarding non-disordered offenders in the criminal justice system. In this paper we propose that single case research methodologies have a part to play in remedying this unsatisfactory state of affairs. The strengths and limitations of single case methods are discussed and comparisons made with RCTs, particularly in the context of dangerous and severe personality disorder (DSPD) services in England and Wales. Important strategic decisions that need to be made in relation to the implementation of single case experimental methods are outlined.

Metacognitive therapy for obsessive–compulsive disorder: A case series

Cognitive-behavior therapy and exposure and response prevention are the most effective psychological treatments for obsessive–compulsive disorder (OCD). However, these approaches often produce variable results with the majority of treated individuals remaining symptomatic. This study evaluated a new form of cognitive therapy based on Wells’ metacognitive model of OCD. Treatment efficacy was assessed using single case methodology in 4 consecutively referred individuals. At post-treatment, all participants made clinically significant change on a range of standardized outcome measures and these gains were largely maintained through to 6-month follow-up. Metacognitive therapy could be an effective and time efficient treatment for OCD.

The aggregation of single-case results using hierarchical linear models.

To investigate the generalizability of the results of single-case experimental studies, evaluating the effect of one or more treatments, in applied research various simultaneous and sequential replication strategies are used. We discuss one approach for aggregating the results for single-cases: the use of hierarchical linear models. This approach has the potential to allow making improved inferences about the effects for the individual cases, but also to estimate and test the overall effect, and explore the generality of this effect across cases and under different conditions. Keywords: single-case; hierarchical linear model; replication; aggregation ********** Single-case experimental designs are used to evaluate the effect of one or more treatments on a single case. The case may be a subject or another single entity that forms the research unit, such as a school or a family. This entity is repeatedly observed, over the levels of one or several manipulated independent variables (Onghena, 2005). In the most basic design, the AB-phase design or interrupted time series design, the case is observed repeatedly during a first phase (A), typically a baseline phase before an intervention takes place, and in a second phase (B) after or during an intervention. To evaluate the effect of the intervention, scores in both phases are compared. Single-case designs have a long history in behavioral science (Ittenbach & Lawhead, 1997), but the last decades, single-case methodology has further been elaborated, aiming at improving the internal validity of the conclusions. For instance, reversal phase designs (e.g., an ABAB-design) or alternation designs with rapidly alternating conditions (e.g., an AABBBABAABB-design) rather than a simple AB-phase design may be used in order to assess or control statistically for the effect of history, maturation or other time-related confounding variables. The effect of such confounding variables may further be controlled by means of randomization while setting up the study, for instance by randomly assigning measurement occasions over treatments or randomizing the time of intervention (Edgington, 1996). Although group designs receive much more attention in methodological courses and handbooks, in the last decades there has been renewed interest in single-case designs, especially in behavior modification and clinical psychology (Barlow & Hersen, 1984. Kazdin, 1982), neuropsychology (Caramazza, 1990), psychopharmacology (Cook, 1996), and educational research (Kratochwill & Levin, 1992). The popularity of the designs is also reflected in the relatively large number of articles published in the Behavior Analyst Today that discuss or apply a variety of single-case designs (about twenty between 2001 and 2006). Single-case designs indeed are very attractive in several situations (Franklin, Allison, Gorman, 1997; Onghena, 2005). Single-case studies may be relatively easy to set up and are much less expensive than large-scale group-comparison studies. This makes the designs also attractive for practitioners, who want to get a first insight into the effect of a treatment. An additional strength of single-case designs is that, in contrast to group designs that give insight into the average effect of a treatment, they give an in-depth insight into the behavior of one single case. Especially in clinical settings, the research indeed often focuses on the effect of a treatment for a specific case. Finally, since only a single case is investigated, the design often allows making a large number of repeated observations, enabling a detailed study of the evolution of the behavior. Single-case designs thus are (initially) aimed at drawing valid conclusions regarding one entity. Sometimes, for instance in applied clinical settings, the primary interest may indeed be in this single entity, since it concerns a case that presented itself with a problem to solve. …

Enhancing accountability in behavioral consultation through the use of single-case designs.

Single-case design and progress monitoring methodologies are efficient and cost-effective strategies for increasing accountability for indirect service provision. Single-case design conceptualizes the treatment of an individual as an experimental process that can be monitored over time and evaluated for effectiveness. Increasingly in clinical, counseling, and educational settings, interventions are administered through indirect service (i.e., behavior consultation) due to the large unmet need within children's mental health and the limited number of child-focused professionals available to address these challenges (Kataoka, Zhang, & Wells, 2002; Meyers & Nastasi, 1999). Single-case methodologies offer clear feedback and treatment evaluation through charted progress monitoring that consultees can understand and interpret. Keywords: behavior consultation, single-case designs, accountability, visual analysis. Historically, psychological service provision has most often occurred without direct accountability for service outcomes. Practitioners report that the techniques that they use in clinical were learned during their training and then altered based on trial-and-error experience (Hayes, Barlow, & Nelson-Gray, 1999). This subjective of altering and administering treatment techniques may occur due to the need to adapt known techniques to an individual client's needs given resource constraints. While the primary goal of any treatment is that the client benefits, designing a treatment that facilitates the quantitative analysis of treatment change results in the ability to both a) establish a correlation between the client's treatment and outcome and b) develop empirical support for the future use of the treatment for a similar presenting problem and client. One way to address the need for increased accountability for service outcomes in applied settings is through single case design outcome and progress monitoring methodologies. Single case design conceptualizes the treatment of an individual as an experimental process that can be monitored over time and evaluated for effectiveness. Rather than relying on anecdotal evidence of change as a result of the intervention, single case interventions are designed for the unique presenting needs of a client, and then the impact of the individual's intervention is monitored over the course of implementation using data collection and analysis techniques. The past 10 years have witnessed an increasing commitment to within the fields of education and psychology. The evidence-based practice movement developed out of calls for increased accountability and transparency in service provision. The field of psychology has committed to researching and documenting the usefulness of psychosocial treatments for mental health problems (Kazdin & Weisz, 2003). Similarly, in the field of education, recent legislative mandates such as the No Child Left Behind Act have emphasized the need for educational practitioners to use instructional techniques that have research-based support (U.S. Department of Education, 2007). As professionals involved in the cognitive and social-emotional development of the nation's youth, psychologists, social workers, and educators need to develop efficient systems for evaluating and documenting the effectiveness of their service provision. This article presents a model for using single-case design methodology to evaluate the effectiveness of interventions, and in particular interventions delivered through indirect service approaches.

Behavioural symptoms of dementia in residential settings: A selective review of non-pharmacological interventions

For people with dementia living in residential settings, behaviours such as aggression, screaming, restlessness, agitation and wandering are a frequent reason for referral to specialist mental health services for older people. Psychosocial models of dementia have grown in prominence and non-pharmacological interventions have been recommended in professional and government policy statements, either as a first line of treatment or alongside medication. Studies of their effectiveness have been criticised for being poorly controlled, focusing on milder behaviour problems and for requiring a disproportionate use of resources. The recent ruling that risperidone and olanzepine should not be used to control behavioural symptoms in dementia makes it timely to review the evidence for alternative treatments. The current review is a selective one of different types of studies including studies of staff training and liaison interventions, studies of a range of different therapeutic interventions and individualized interventions within a single-case methodology. It is argued that different types of research methodology are appropriate for different studies and that there is still too little evidence to provide firm guidelines. In conclusion, a structured decision-making process for selection of interventions is proposed, in which the limited available evidence can be drawn together to provide a basis for targeting clinical resources while the research evidence is strengthened.

Single-case experimental designs: applications in developmental-behavioral pediatrics.

This article discusses single-case experimental designs (SCEDs) and their relevance to developmental-behavioral pediatrics. Information concerning SCEDs have not been described in the Journal of Developmental and Behavioral Pediatrics, despite its relevance to the field. General issues related to the underlying logic and applications of SCEDs are reviewed with examples selected from the literature to illustrate the strengths and weaknesses of different design strategies. It is suggested that SCEDs can be a useful alternative to traditional between-group designs for clinical and evaluation research because the unit of the analysis is the individual; therefore the feedback to clinicians and families is direct about the effectiveness of a behavioral intervention or medication for that individual. In the field of developmental-behavioral pediatrics, SCEDs can be especially useful in the management of vague symptoms or poorly defined diseases to improve the confidence in a treatment decision for an individual patient. This report is intended to facilitate the understanding and use of single-case methodology so that clinicians are aware that flexible, true experiential designs exist to fill the gap in knowledge and also "do the best for my patient."

An assessment tool for investigating paedophile sexual interest using viewing time: an application of single case methodology

SummaryThe present paper describes the development and piloting of a computer‐based single case methodology for the assessment of paedophile sexual interest in people with learning disabilities. Clinical, methodological and ethical issues with respect to the assessment of sexual interest are raised. Data from a series of assesments is presented graphically and the implications of the findings are discussed.

An evaluation of statistical procedures for comparing an individual's performance with that of a group of controls

The single case methodology that is widely used in cognitive neuropsychology often requires a comparison of data from a single individual (the patient) with that from a group of controls, in order to ascertain whether the patient's mean score can be viewed as significantly different from that of controls. This article reviews methods that have been used to deal with such data. Although Analysis of Variance (ANOVA) provides one possible solution of comparing group means, unequal group sizes and differences in variability between patient and controls can violate the assumptions of the test. Using Monte Carlo simulations, it was found that differences in group size and a group of N = 1 did not significantly affect the reliability of the analysis. In contrast, unacceptably high Type I errors were obtained when, in addition to unequal group sizes, there were relatively modest differences between the variance of the patient and that of the controls. We suggest that ANOVA can be used for the comparison of the mean score of an individual with that of a group of controls, but that when there is a difference in variability between the two groups, revised F criteria should be used in order to make the analysis reliable. A table of modified F values is given, which can be used for various departures from homogeneity of variance.

Knowledge diffusion in social work: a new approach to bridging the gap.

The continuing gap between research and practice has long been a problem in social work. A great deal of the empirical practice literature has emphasized practice evaluation (usually in the form of single-case methodologies) at the expense of research dissemination and utilization. An alternative focus for social work researchers can be found in the extensive theoretical and research literature on knowledge diffusion, technology transfer, and social marketing. Knowledge diffusion and social marketing theory is explored in terms of its relevance to social work education and practice, including a consideration of issues of culture and power. The authors present an integrated dissemination model for social work and use a case example to illustrate the practical application of the model. The OPTIONS (OutPatient Treatment In ONtario Services) project is an example of the effective dissemination of two research-based addiction treatment modalities to nearly 1,000 direct practice clinicians in Ontario, Canada.