Single-case Multiple Baseline Research Articles

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

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

Enhancing Grapheme-Phoneme Correspondence Learning: A Single-Case Study Using Picture Mnemonics

The ability to recognize and name the sounds of alphabet letters is a crucial prerequisite for students as they embark on their journey to learn how to read. Regrettably, some children face significant challenges in this area. In this single-case multiple baseline study, we utilized mnemonic pictures to facilitate the memorization of the grapheme-phoneme correspondence of ten target letters. Our aim was to empower four struggling first-grade students to quickly and confidently retrieve this information. The results reveal that the students significantly benefited from the intervention. Furthermore, the approach was perceived as attractive and helpful by both the four children and their teacher. The study concludes by reflecting on its limitations and discussing potential implications and future avenues of research.

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

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

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 Self-Monitoring to Increase Behavior Specific Praise in Elementary Classrooms.

Teachers need simple, easy to implement, evidence-based interventions to use in their classrooms. A single-case multiple baseline across participants design was used to determine if the use of self-monitoring in isolation would increase educators' use of behavior-specific praise (BSP). Participants tracked their use of BSP using a hand counter when they taught content area classes (i.e., science, social studies) and during a time of transition during the generalization phase. An increase in educators' rate of BSP was seen when self-monitoring was used. Data revealed that the rate of BSP per minute was higher during the generalization phase than the intervention phase. • Cost and time efficient way to: - Teach self-monitoring - Increase staff use of BSP - Generalize use of BSP.

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

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

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

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

Telehealth Training in Naturalistic Communication Intervention for Mothers of Children with Angelman Syndrome.

Objectives Young children with Angelman syndrome have significant delays in expressive communication. Parents of children with Angelman syndrome require training to support their child’s communication development. Unfortunately, parent training focused on the needs of families of children with rare genetic syndromes is unavailable to many families. The purpose of this study was to evaluate a telehealth parent training program on naturalistic communication intervention for young children with Angelman syndrome.MethodsUsing two single-case multiple baseline designs across a total of six parent–child dyads, we evaluated the effects of a telehealth parent training program on parent implementation fidelity of a naturalistic communication intervention, child communication, and child engagement.ResultsWith the telehealth parent training program, parent implementation fidelity of naturalistic communication intervention improved, maintained and generalized to untrained home routines. Small effects on child communication and engagement were observed during the program.ConclusionsParents of children with Angelman syndrome were successfully taught via telehealth to implement a naturalistic communication intervention with their child at home. Additional research is needed to promote positive child communication outcomes through parent-mediated intervention.

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

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

Remote Delivery of Prevent-Teach-Reinforce for Families

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

Effects of a Peer-Mediated Joint Attention Intervention in an Inclusive Preschool Setting

Joint attention, or shared attention to an object or event, is a pivotal skill for the development of social interactions and social communication. Joint attention typically develops in natural contexts within the first year of life. Children with autism spectrum disorder (ASD) and related developmental disabilities often experience difficulty developing joint attention. Clinical interventions to increase joint attention exist. However, there are limited studies investigating methods to incorporate joint attention interventions in inclusive preschool classrooms with peers as social partners. For young children in preschool settings, peer-mediated social skills interventions reflect natural contingencies and may promote generalization. In this study, we employed a single-case multiple baseline across child–peer dyads design to evaluate the effects of a peer-mediated joint attention intervention for children with or at risk for ASD on response to joint attention (RJA) from peer bids and initiations of joint attention (IJA) from target children with ASD. The intervention included direct instruction with a social narrative to teach three peers to initiate bids for joint attention to measure target children’s responses. Target children later received the same direct instruction to increase IJA to same-age-peers. Results indicate increased target child RJA and IJA to peers. Limitations and implications for research and practice are discussed.

Using Errorless Learning and Discrimination Training to Teach Early Literacy Skills in a Pre-School Setting

This case study investigates the effects of using an intervention package of errorless learning and discrimination trial training to teach a 4-year old preschool student to read Consonant-Vowel-Consonant (CVC) words. A single case multiple baseline design across three equal instructional sets was used to evaluate the effects of the intervention package. Each set contained six CVC words incorporating words with each of the five vowels. The results of this study indicate that utilizing both errorless learning and discrimination training to teach a preschool student how to read CVC words was effective. In addition, generalization assessments post-intervention showed an increase in (a) mastering new unknown CVC words, as well as (b) book text reading.

A 25-Year Review of Nighttime Fears in Children: Past, Present, and Future.

Nighttime fears in children are common, interfere with daily functioning, and result in considerable disruption in the family. The aim of the present review was to examine empirical literature from the past 25years that investigated the assessment of nighttime fears in young children and the efficacy and effectiveness of psychosocial treatments for children's nighttime fears. The last review of this literature was in 1997 and examined studies conducted in and prior to 1995 (King et al. in Clin Psychol Rev 17:431-443, 1997). Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review of the literature aimed at providing a synthesis of the Randomized Control Trials (RCTs) and controlled single-case multiple baseline design studies (MBLs) on the treatment of nighttime fears in children. A search of the literature identified 12 articles, with nine studies utilizing a between-group randomized controlled trial design and three studies utilizing a multiple baseline design. Results demonstrated significant improvements in children's nighttime fears and reductions in disruptive nighttime behaviors using behavioral interventions and cognitive-behavioral strategies. This review provides a commentary on the effectiveness and limitations of the assessment and treatment approaches for nighttime fears in children and suggests directions for future research.

Using Peer Coaches as Community-Based Competency Drivers in Part C Early Intervention

Using an implementation science framework, this study examines the impact of a multicomponent professional development (PD) approach implemented by internal peer coaches on early intervention providers’ use of Family Guided Routines-Based Intervention. The experimental study used a single-case multiple baseline design across participants, replicated in three sites with early interventionist (EI) providers ( n = 9) and families with infants and toddlers ( n = 18) in U.S. community-based Part C programs. Data indicate a functional relation between the multicomponent PD approach and EIs’ use of the intervention. A between-case standardized mean difference effect size was used to confirm the results of the visual analysis. The implications for the use of implementation science frameworks to build competency drivers within early intervention systems are discussed.

Implementing Electronic Check-In/Check-Out to Reduce Challenging School Bus Behavior

The purpose of this study was to explore the efficacy of an electronic check-in, check-out (eCICO) intervention. The district’s case manager (i.e., guidance counselor) implemented the eCICO intervention remotely via FaceTime on an iPad in collaboration with the bus driver who facilitated student wireless internet access to a mobile hot spot. Results of the single-case multiple baseline across behaviors study suggest a functional relation between eCICO and the target bus behaviors of two rural students with emotional and behavioral disabilities. Further, low rates of target behaviors were maintained after eCICO was withdrawn. Implications for implementing eCICO interventions, limitations, and future research directions are discussed. Results of the study are reported using visual analysis, Tau-U, and percentage of non-overlapping data points.

A single-case multiple baseline design for treating insomnia in eating disorders: The TIRED study.

The purpose of this trial is to evaluate the novel use of an empirically supported treatment for sleep problems for people with residual insomnia disorder following ED treatment. Participants (N = 6) will complete a single-case multiple baseline study using Brief Behavioral Treatment for Insomnia (Buysse et al., Archives of Internal Medicine, 171, 2011, 887-895; Troxel et al., Behavioral Sleep Medicine, 10, 2012, 266-279). Participants will complete pre- and post-treatment evaluations of insomnia severity, sleep efficiency, daytime fatigue, ED symptoms, depressive symptoms, and anxiety symptoms. Throughout treatment, participants will complete daily diaries of sleep indices (sleep latency, wake after sleep onset, total sleep time, and sleep efficiency). The primary outcome will be treatment effects on insomnia severity, measured by the Insomnia Severity Index. Secondary outcomes include sleep efficiency and daytime fatigue. Exploratory outcomes include ED-related impairment and symptoms, anxiety symptoms, and depression symptoms. We will provide subject-level graphs of sleep indices and ED symptoms throughout treatment. Additionally, treatment effects will be examined at one- and three-month follow-up. Although insomnia treatments have been evaluated in other psychiatric disorders, there has yet to be a study examining behavioral interventions for insomnia in EDs. Results of this study will inform the development and application of interventions for residual insomnia symptoms in this population.

Auditory Intervention in Late-Identified Children With Hearing Loss

This study examined the effects of a 9-week auditory intervention on the auditory skills of five children with hearing loss who experienced prolonged auditory deprivation before receiving hearing aids. A single-case multiple baseline design across participants was used to examine the effect of the intervention on the children’s auditory skills using a weekly probe. The analyses showed a moderate to high intervention effect for three out of five participants. Children demonstrated gains in detection, discrimination, and identification, and Participant 5 also showed gains in sentence comprehension. Findings provide preliminary support for offering auditory intervention to children with hearing loss who are late identified and aided in the presence of residual hearing.

Power of a randomization test in a single case multiple baseline AB design.

A randomization test can be used to statistically test hypotheses in multiple baseline designs to complement the commonly used visual inspection analysis. A crossed factor simulation study was performed to investigate the power of a randomization test in an multiple baseline design. The results show that the degree of autocorrelation of the observations, the number of participants, the effect size, the overlap of possible start moments of the intervention between participants, the ratio of the number of measurements in the baseline- and intervention phase, a gradually emerging effect, and the number of measurements had strong main effects on the power. The two-way interactions between number of participants and effect size, and between the number of measurements and the number of start moments of the intervention also had a large effect. An online tool was developed to calculate the power of a multiple baseline design given several design characteristics.

A brief behavioral treatment for unresolved insomnia in adolescents: a single-case multiple baseline pilot study, evaluating self-reported outcomes of efficacy, safety, and acceptability.

Insomnia is a significant problem for many adolescents and often is associated with detrimental effects on physical and mental health. Drawing on emerging models of intervention in the adult literature, this pilot study investigated the efficacy, safety, and acceptability of a novel, brief (3-week) behavioral intervention among adolescents with unresolved chronic insomnia. A multiple baseline (staggered start) A-B with follow-up single-case design (n = 2) was used to evaluate intervention outcomes across treatment and at 2-month follow-up in the domains of sleep, mood and affect, fatigue, and parent-child conflict. Outcomes were indexed with multi-informant data collected using adolescent reports on mood/affect and sleep diaries, and parent reports on parent-child conflict. Posttreatment and 2-month follow-up data indicated improvements in self-reported sleep quality, including sleep onset latency and increased sleep efficiency. Indicators related to participant mood, stress, and parent-child interactions remained relatively stable over the course of treatment, suggesting that the sleep restriction component of the intervention did not produce adverse effects for the adolescents or their families. A brief 3-week intervention adapted from the adult literature was associated with improved sleep-wake cycles in adolescents with chronic insomnia. Change during the treatment phase was particularly rapid and maintained over time. In conjunction with low observed risk and adverse effects, the potential for this treatment to provide a safe, acceptable, and cost-effective manualized treatment for adolescent insomnia warrants larger-scale clinical evaluation. Registry: Australian New Zealand Clinical Trials Registry; Title: Does a one month brief behavioral treatment improve sleep for high school adolescents (ages 12-17): an open label pilot study; Identifier: ACTRN12618000835246; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375102.

Teacher-Delivered Training to Promote Paraprofessional Implementation of Systematic Instruction

As paraprofessionals gain more instructional responsibilities for individual students, feasible training strategies must be established to promote effective delivery of instruction. This train-the-trainer study was designed to teach paraprofessionals how to implement an evidence-based instructional practice under the direction of the classroom teacher. After receiving training from a university researcher, a special education teacher trained three paraprofessionals to implement constant time delay while teaching three students with multiple disabilities. The paraprofessional training consisted of a workshop, video modeling, and coaching with performance feedback. A single-case multiple baseline across paraprofessionals design was used to evaluate the effectiveness of the teacher-delivered training package. All paraprofessionals implemented the systematic instructional procedures with high levels of fidelity and accuracy after training. The special education teacher and paraprofessionals shared their perceptions on the highly effective training and value of the study through social validity surveys. Implications and limitations of the study are discussed.